Many state boards of medicine are allowing license reciprocity or expediting temporary licenses for physicians licensed in good standing in another state. This will improve the ability of physicians to continue to treat their patients during the pandemic - including physicians in border towns like yourself. The RI Department of Health is issuing temporary licenses (90-day) to licensed out-of-state physicians at no cost. To apply, simply go to the RIDOH website. health.ri.gov/licenses/

Ms Horvath,
Thank you for the response. I will be applying tonight.
I appreciate your time to contribute to this site. It is exactly what we need!
Chris

Is it not time for the AMA to lead the charge to change the archaic state by state licensing requirements? We know the history of state boards medical licensing, both good and bad, but surely we can find a way to have national licensing and still achieve local oversight of those actively practicing in a given geographic location. For telemendicine/videomedicine etc to achieve its full potential long term we need to be able to consult across state lines etc and have some form of reimbursement follow for those professional services. This would greatly increase the clinical access and reach of major centers to physicians and patients on a national basis. Thoughts?

Of course there are electronic stethoscopes, and smartphones and wristwatches, to do this remotely, but they would be needed at the patient's end. Some of the smartwatches have pulse readers and some do not. Actually, I just went on my Android to see what I could find. Located an app called Heart Rate Monitor. Downloaded it. You put your finger directly on the camera, and it displays a graph plus the heart rate. Amazingly cool! Attached. If you look at this graph and think I'm dying, please send me e-mail at your earliest convenience within the next 7 days.

It is an important point and some would say "there's an app fpr that." There are a lot of remote monitoring devices and the AMA has been focused on that as well. I think AMA staff could identify some links to those resources. Lung sounds are always best with a hands-on exam with all of the other nuances we become facile with assessing patients, but there are apps for that too. If this covid moment persists, we may find out how well they work

I agree! Where to listen, how to listen-- all the things we are taught-- would be tricky without at least a bit of training. Difficulty of lung sounds > heart rate & rhythm, I think. Without advance training, we could probably still teach people, remotely, to echo their heart beats audibly, but this might benefit from a bystander doing the same thing concurrently for that person, to validate the findings. I'm not aware of studies about this, but there might be some. These are all makeshift "DIY" methods, of course. Use at your own risk!

I have also heard of doctors doing video visits with patients and asking them to collect vital sign information while they witness. Not the most efficient way to do it but as we rush to get everyone cared for it is simple and straightforward.

We currently have patients report their vital signs when we do Televisits. I found an App called Cardiograph in the App Store on my iPhone. However, I worry about my 80 and 90 year old patients ability to find & download app, open app, hold their fingers on the camera and then show me the phone in the webcam.
I have diagnosed countless number of 80 & 90 year olds with atrial fibrillation triggered by detecting an irregular pulse on examination who came in the office for "routine" visits. We need to improve the ease of use of this type of App for our elderly patients.

Dr Zimmer’s question is important. I am going to bring up a pertinent coding related issue, as it relates to the physical exam. But, first I want to make it clear that I am not questioning the importance of the physical exam and I am not suggesting it is not necessary or that it can be replaced – that is a decision based on each physician and his/her patient based on clinical (and practical) considerations.

Here is the coding consideration: The documentation requirements for the new patient E/M codes require a physical exam, which telehealth generally does not enable. For these new telehealth provisions to be useful from a practical perspective, the physical exam requirement would have to be waived. And it is not just Medicare which will need to waive that requirement, but also the private payors.

It is my understanding that the AMA and others have reached out with just that recommendation.

For the established patient codes, a physical exam is not required, as long as history and medical decision making are performed. Therefore, less of a consideration for those codes.

There are several apps available that claim the ability to capture one or more vital signs. However, the reliability and safety cannot be guaranteed. Safer route is to make available the integrated peripherals that can send periodic or real time data to the EHR. It is feasible (and cost effective) for a hospital system or an ACOs but may be challenge for independent practitioners until the EHR vendors start offering it as a feature.

Thanks for sharing, Ethan. I appreciated Jay's comment: "Telehealth needs to support ongoing relationships, not transactions" - particularly important for ensuring continuity of care

That is an excellent LinkedIn post. Everyone is watching TV. Today's Internet-based TV accepts responses to users' input. Can't we use TV to track, answer questions, and help people with questions and symptoms relating to COVID19? We need the TV networks to organize with the healthcare community. Let's do it!

I agree with many points that the article makes and I am a huge fan of asynchronous telehealth. I also think it's important that local docs are using these technologies to see their own patients, because understanding the local situation is really important. For example, in NY and NJ, now that we are under general shelter in place restrictions, we have also pulled back from testing even high risk symptomatic persons. So it would be important to understand that many patients there should NOT be referring to drive through testing, unless they meet criteria as essential workers and are a COVID spread risk. Questions like that have little to do with modality, and much more to do with the provider behind the modality... a much overlooked piece of the puzzle.

Async has an important role, because in general, async is more efficient for issues that are clearly non-urgent, whereas the converse is true for urgent or potentially urgent issues (demands synchronous or live communication). So sync and async should always go hand in hand in the healthcare context. In many cases, patients know in advance that they have a non-urgent question or issue. Stopping those issues from the sync mode frees up the bandwidth and access for higher priorities. In the VA, e-mail from patients requires no immediate response but does always require a response within 72 hours.

My VA medical center is using a specific screening algorithm to determine which patients should go to the drive-thru testing tent. Clinicians are on hand to serve as consultants to review cases and triage them to the drive-through or elsewhere, depending on what criteria are met. Only the approved cases can get to the drive-thru.

To Michael's point above, ideally, we should be finding ways for synchronous and asynchronous providers to work together closely to meet patients' needs. As Jay wrote, patients are waiting hours to get any sort of healthcare related guidance even before they consider a virtual visit. Most patients have no idea if a video visit is even right for them, since they've likely never used it before. We needs ways for patients to reach an on-demand, asynchronous provider (ideally RN or advanced practice) in minutes, who can empower the patient with calm, personalized health information and guidance, based on Jay's risk strat. Those patients can then be escalated to a video visit or testing site as indicated. However, many patients can be empowered to care for themselves at home, just through a quick, low-cost, asynchronous modality, such as HIPAA-compliant text messaging. Really, we need the tried and true nurse triage/call centers to be revamped into a 21st century asynchronous model that meets peoples' current expectations.

Yes, Igor, I agree, though I'm not sure what type of product is actually better than a call center, provided people do not get put on hold! I would like to know if the group has found anything helpful. I hate phone trees! Chatbots seem like they hold promise for the future but not so much the present, based on my experiences so far.

The question of synchronous and asynchronous communications is important, and I appreciate Ethan raising it. Dr. Parkinson’s point about continuity of care being a necessity is hugely relevant.

In addition to my interest in telemedicine, I am also involved in CPT code creation and valuation, so bear with me, while I dive into some coding. The AMA has embraced the importance of creating asynchronous CPT codes, to complement synchronous ones. I will discuss a few.

Much of our discussion on telemedicine and Covid-19 has centered on synchronous telemedicine interactions being treated the same as face to face – Evaluation and Management Codes being the easy example. But there are recently created codes for asynchronous online communication, such as the standardized questionnaire Dr. Parkinson describes. Those codes are 99421-23 and are based on the time the service is provided (i.e. – 5-10 minutes).

Another example relates to physician to physician consultation where we have codes (i.e. - 99446-9, also differentiated by time), which may be synchronous, such as via telephone. But they can also be asynchronous such as via an EHR or the internet.
Granted coverage and payment for these codes should be robust, but the ability to report such services exists. It is a start. Now, getting back to Covid-19 and the continuity question. The complex nature of Covid-19 is far more than a series of single, transactional, time-based interactions. Rather, it requires continuous and coordinated actions across multiple local, regional, and national physicians and providers. Here, too, there are codes for coordination of care which form a reasonable starting template.

However, Covid-19 is, and will, create a need for us to explore new and innovative payment models ready to address a need of this magnitude. We have lots to learn.

As a practicing intensivist/pulmonologist I found the system of portals, ehr's all about connecting billing and data and not about patients and doctors. I had to do it myself and spent 3 years making a dream system that is now ready to help with the COVID-19 epidemic!

I created ListenMD a communication system that allows patients to connect asynchronously with doctor office, and doctor to text and video chat at the DOCTOR's convenience. Patient and doctors manage the caregiver list and all (irrespective of location,EHR, organization) the patients doctors can text and share images with each other with a patented 'Distraction-free messaging' We doctors have to respect each others time but also connect as humans rather than just doing 'interoperatibility' and getting more data overload.

Please feel free to load 'ListenMD doctor' app and invite patients load 'ListenMD' app. This free for all at present given COVID19. I am using my apps in office and in hospital.

vimeo.com/397421063

"Telemedicine" is a broad category encompassing multiple technologies that include both Asynchronous and Synchronous tools. Asynch allows for the time shifting of care for lower acuity issues while as as capabilities to monitor patients pre and post surgery or visit. Companies like CaptureProof have provided great asynchronous tools which use AI for image processing in a number of compelling use cases in Ortho, Neurology and the Pharma markets. Also know as store and forward telemedicine, Asynch allows providers to organize their workdays to be efficient and respond within reasonable timeframes. It also does the same for the patient. It will absolutely be an important part of delivering a continuum of care in our healthcare systems future.

Dr. Christianson, You are right, the focus has been on physicians providing telemedicine to help triage COVID-19 patients and continue to provide care to their existing patients. But licensing is only part of the solution, credentialing needs to be addressed as well. A few Governors have already addressed this issue, such as Governor Cuomo (NY), Governor Baker (MA) and Governor Mills (ME).

Emergency temporary privilege's are being granted by hospitals to help address the situation where warranted. Telemedicine is being more broadly used B2B than any other use currently and saving lives everyday in underserved communities.

hcinnovationgroup.com/covid-19...

We certainly have great needs for more "clinical telehealth" or clinician-to-clinician telecommunication. A broad need that remains unmet is the need for a more global referral network that would vastly expand access to specialists, especially for small hospitals and rural areas. Many of today's referral networks still tend to exist within small geographic areas or "closed" systems.

To echo Jamey Edwards, we are hearing of hospitals that are exercising the disaster credentialing plan described in their medical staff bylaws. These plans define expedited processes for credentialing and privileging and apply to both physicians that have already been credentialed by the hospital or system and need broader privileges and physicians who have not yet been credentialed by the institution.

Thank you all for your replies. I am an Emergency and Telehealth Physician. TeleTriage is easily adaptable to ED/Hot Zone Covid-19 screenings. It sounds like this could actually be turned on pretty quickly with outside help - at least in some state. We are about to release a white paper on this use, if anyone is interested. The trick is getting the information to the right people.

Hospitals also seem to be adapting and increasing remote interactions without specific telemedicine platforms, often using their existing clinician-to-clinician messaging platforms (e.g. Epic Secure Chat) and even Zoom: neither was built for tele medicine per se but both allow for video, phone, and text and are relatively widely available and user friendly.

I created ListenMD and can keep my hospital rounds list and billing, connect and message other doctors in my team and across teams and also send patients one link to do HIPAA compliant video chat and then voice text what I did to get a note faxed to the nearby printer that can be scanned in Cerner (eventually) As a pulmonologist, I am getting my history on video chat and entering COVID19 rooms for shortest time needed. Please try free app 'ListenMD doctor' and give feedback
vimeo.com/397421063

At Partners Healthcare we have a lot of experience with physician to physician econsults, done right in the context of Epic. This works quite well as a tele-triage tool and every specialty has been involved at some level.

Jason I would be interested in this paper. Who do you work for? yaqutap@gmail

Here is the link: mailchi.mp/023c217877a7/white-...

and. of course, the Steps Fporward module, edhub.ama-assn.org/steps-forwa...

It should be a routine part of the practice schedule. As a pediatrician, it is a valuable triage tool and I have been using telemedicine for psychopharm f/u's for over a year with great success and patient satisfaction. In my practice area, travel and wait times can be formidable and telemedicine is a blessing for all. I have developed visual templates for a physical exam and a number of condition specific visit templates. If you have felt the loss of patient visits to commercial telemedicine sites and the explosion of urgent cares and RBC's, this is the way to recapture and maintain the medical home.

Digital Health just went from Blockbuster to Netflix in a week. I don't think you can put that genie back in the bottle.

Short answer: YES. Medicine has been too long on the sidelines in terms of using technology to increase the reach of physicians. Now is the time to push forward for appropriate reimbursement while government and private payers are realizing the great advantages and overall cost savings available

It is long past due for ALL payers to recognize and reimburse telehealth visits at or close to the same rates as office visits. They save all parties time and money. The rapidly advancing use of monitoring adds to the collection of data needed to enhance judgements made by physicians.

It is long past due for there to be national licensing for physicians. The absurd notion that crossing a state line renders your medical and surgical knowledge obsolete must end. Heart disease, cancer, injury, contagion etc., do not suddenly change whether in California, New York or in between.

Clearly, we are at an inflection point. The time for talk and half measures should be over. These are just two basic changes, along with others, that should see relatively swift implementation.

Great question! Kaiser and the VA do over half their visits currently over telemedicine so the model is proven to work. Telemedicine is a group of technologies (chat, audio, video, email) that should be integrated into daily practice, helping to reduce office visits, save travel and waiting room time, minimizing healthcare's carbon footprint, and seeing patients where they are most satisfied (home and work). This is the natural evolution of healthcare's digital transformation. In addition, the B2B telemedicine market in our country has been thriving for many years. I also think behavior change takes time (adoption curve), unless there is a catalyst. Coronavirus has provided the exact catalyst to force people onto telemedicine platforms. Once people gain some muscle memory here in using the services, I believe consumers will continue to vote with their keyboards and cameras (and feet) :)

We'll need more research into what can be done safely and effectively without physical presence. There are studies about that issue for selected conditions and specialties, but we still know too little. I agree that remote monitors (BP, glucose, body weight, EKG, etc.) have changed the game, but evidence is still lacking about many issues. VA has done some innovative work such as two-step dermatology evaluations: they take a photo first, and look at it remotely or asynchronously. If it looks worrisome, they call the patient into the office for a closer look. This saves the precious office visits for the people who really need to be seen. Many derm conditions can be treated based on a photo alone. Wearables will provide the next wave of action, but also with potential to generate an overwhelming amount of data that can be difficult for even a skilled and experienced physician to interpret. The home-based continuous glucometers are undergoing quite a bit of evaluation and research at this time.

It will also be very important for us to have a unified message to payers and regulators as the dust settles, so we don't end up going backwards

What was categorized as innovation just became regular work. While direct to patient telemedicine with continue with significant demonstration of its efficacy as a covered service, the next step would be to also advocate for provider to provider models specially for areas with critical shortage of specialists.

Six telehealth provisions under new legislation in Maryland:

1. ASYNC. Adds asynchronous telemedicine to Maryland's telehealth guidelines

2. RELATIONSHIP. Allows providers to use telehealth to establish doctor-patient relationship.

3. CONTROLLED DRUGS. Establishes guidelines for use of telehealth to prescribe controlled substances.

4. MENTAL HEALTH (Medicaid). Requires Maryland Medicaid to provide telemental health services to patients at home.

5. CHRONIC DISEASE MANAGEMENT (CMS). Requires Maryland's health department to pursue chronic care management via telehealth under CMS.

6. SUD (Medicaid). Requires Maryland's health department to study whether telehealth can be used effectively to treat substance use disorder among Medicaid recipients.

mhealthintelligence.com/news/m...
mgaleg.maryland.gov/2020RS/cha...
mgaleg.maryland.gov/2020RS/cha...
mgaleg.maryland.gov/2020RS/cha...
mgaleg.maryland.gov/2020RS/cha...

The issue around payment for preventive care is extremely relevant and may be necessary for the care of patients and the survival of primary care physician practices. Obviously CMS has not deemed it reimbursable nor have any commercial insurers that I know of, but if the situation persists we will have to be creative about providing well care and immunizations. I am appealing to the governor of Va where I practice (pediatrics) to issue an executive order mandating payment for well care.

Regarding drawbacks, and thinking longterm-- beyond the fact that certain preventive services (like immunizations, as mentioned above) need to be done in person, patient centeredness and maintaining and measuring quality is always a concern. Especially when it comes to things like advance care planning. Building rapport, assessing understanding, proper consent are all possible via telemedicine, just as they are in-person. But these activities all require some delicate effort and attention to make patients and clinicians comfortable doing this via telemedicine.

Thanks for the quick response, Dr. Libby! It sounds like I may be misreading the nature of the 1135 waiver.

Would these services fall under the "Medicare Telehealth Visits" category addressed in the recent CMS Fact Sheet (cms.gov/newsroom/fact-sheets/m...), since they're included in the full list of covered telehealth services linked in the table from the CMS fact sheet (cms.gov/medicare/medicare-gene...)?

Thanks, Dr. Lee. Great points about the delicate nature of ACP discussions and the challenge of conveying empathy over a digital medium.

If you look at the codes identified they are not preventive care codes. Certainly one can take specific chronic conditions and bill using the listed E&M codes.

And I agree with Dr Lee about face to face and hands on care when it is possible.

This is a good review and has some links to an xcel list of codes, none of which are preventive care codes
medicaleconomics.com/news/coro...

I agree with Dr. Lee. Aside from the issues about payment, coding, and procedures such as immunizations, the issue of patients' expectations is an interesting one. Many patients have an expectation that an annual assessment will include a physical examination. If they don't get it, they feel "short-changed". Especially with an increasing evidence base that suggests careful targeting of the physical examination, aligning practices with expectations, without providing overuse of services, is especially important. Ideal intervals for most types of general and preventive care are poorly understood and not commonly studied. In addition, whether a remote "annual exam" is medically feasible may depend partly on whether the patient is reporting to the office at other times during the year, when in-person requirements can be met (again, thinking medically and not specifically regarding coding requirements).

Most payers are using the same codes. It is easy enough to test codes through your business office or billing manager. There may be variations on some nuances of billing between commercial insurers.

Some payer policies vary by state. In Texas, Governor Abbott directed TDI to issue emergency rules requiring state-regulated plans to pay for telemedicine and telephone visits at the same rate as an in-person visit.

2/ (2)How physicians / QHPs are paid:

These changes apply only to the Medicare program. Private payors may enact similar provisions but that will vary and is not immediate. These telehealth services will be paid under the Medicare Physician Fee Schedule and at the same amount as in-person services. For instance, an office E/M service could be provided by telehealth in the home and paid at face-to-face payment rates. Medicare coinsurance and co-pay still apply. This applies to all patients, not just those affected by the virus. When billing for these services, the Place of Service code is: 02-Telehealth. No billing modifiers are required.

If there is a difference in the fee schedule between physician office and facility payment, the facility payment is applied. The established patient requirements are waived. In other words, during this emergency, it is not required that the patient have a prior relationship with the patient. These changes only apply to physicians / QHPs, not facilities which bill from other fee schedules such as the OPPS or IPPS. But facilities may be able to bill the originating site facility fee.

It is also worth noting that there are several other recently enacted telehealth services which are available such as virtual check-ins, online digital visits, remote patient monitoring, telephone evaluation and management and remote consultations.

3/ (3) Which technology may be used:

A wide range of communication tools, including telephones with video and audio capabilities may be used. Others include mobile computing devices capable of two-way, real time interactive communication, such as Skype. Straight audio communications, such as a simple telephone are not included.

Here is the link to the CMS info...
cms.gov/newsroom/fact-sheets/m...

Thanks for synopsis of the recent policy changes! Wanted to note that per OIG the cost-sharing may be waived. This is from CMS' new telehealth fact sheet: "The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs."

The AMA is working hard to persuade CMS and commercial insurers to also include audio only communications (telephone calls) during this public health crisis.

Congratulations to the AMA on pursuing approval for audio-only communications. This is a patient-centered approach that will often meet the patient's needs more closely, while still providing valuable information-- sometimes just as good as audio+video in terms of key "lessons learned" about the patient. Even in the 21st century, with a plethora of video tools, I am amazed to see the persistence of so many challenges with video communication and technologies: poor lighting, wifi dropouts, problems with bandwidth and quality of service, bad cameras, inadequate training, and most commonly, inadequate usability of systems.

hhs.gov/hipaa/for-professional...
OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This notification is effective immediately.

While the government has waived these requirements, will Physicians and patients feel comfortable risking their data? And will physicians be released of all legal liability should a patient information breach occur?

OCR's relaxation of the regulations during the COVID-19 emergency primarily extends to the platforms clinicians use for a telehealth visit. For example, technology tools such as FaceTime and Skype are temporarily permitted even though this technology is not encrypted nor HIPAA compliant. Physicians should continue to document the patient visit within the EHR and apply the same standard of care as though the visit happened in person. There is no reason for PHI to be stored via the unsecure communication tools.

What about the ability for some of these platforms (like Webex, zoom, etc.) too record and store data on their servers? Documentation may not take place on the platform but if the information is recorded somehow its still a vulnerability, correct?

@LindseyWilliams, that is an excellent point. I'm not familiar enough with all of the platform capabilities, but visits should not be recorded and saved.