Telemedicine and COVID-19

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Telemedicine and telehealth tools play a critical role in the management of patients and provider workflows during the COVID-19 pandemic.Recent changes in state and federal public policies have broadly enabled the adoption of telehealth solutions in this public health emergency. In particular, Medicare and (and some Medicaid programs) have expanded telemedicine and telehealth services. The federal government has waived HIPAA enforcement actions for the use of non-HIPAA compliant communications devices, and eliminated the state licensure requirement for federal programs.  Practitioners should be keenly aware of state privacy and security, prescribing and licensure laws.

During the COVID-19 pandemic, virtual care methodologies are being used to:

  1. Reduce patient and provider exposure, in hospitals, clinics and other settings.2
  2. Reduce the need for personal protective equipment (PPE).
  3. Evaluate and treat persons under investigation and monitor Covid19 positive patients.3
  4. Care for acute and chronically ill patients (at greatest risk for exposure in traditional in-person settings) through telemedicine provided to patients in their homes including though urgent care telemedicine and remote patient monitoring tools.
  5. Support healthcare facilities such as community hospitals, skilled nursing facilities, long term care facilities, and correctional facilities.
  6. Provide structured “curbside consults” through eConsult programs.4
  7. Support alternative care delivery sites with specialty expertise, and
  8. Educate providers through virtual methodologies5

In-hospital telemedicine:

In in-patient and emergency department settings, telemedicine has proven to be invaluable to reduce exposure, and mitigate shortages of personal protective equipment (PPE). Models include the deployment of secure telemedicine endpoints inside isolation rooms linked to a central location or the nurse’s desk, in support of secure video and audio communications. Staff can communicate with the patient and other staff members from outside the room to help with clustering of care, relaying of messages, and communicating with patients. Specialists can consult remotely. Families are able to use these connections to communicate with patients during times of visitor restriction.

Hospital to hospital (or other facility) telemedicine:

With expected critical bed shortages, telemedicine solutions can be readily deployed in support of community hospital ED, critical care, or other inpatient collaborations.   Telemedicine solutions can also be utilized in support of skilled nursing and long-term care facilities, both in the management of COVID-19 patients, and in the management of medically fragile patients for whom transport to the emergency room creates unnecessary risks of exposure.

Screening, urgent care, and remote monitoring:

Healthcare facilities are seeing a dramatic influx of patients with symptoms that meet criteria for testing and must address how to manage these patients while also protecting community members from infection. Many patients with COVID-19 will not require hospitalization.  Urgent care and clinic-to-home models of telemedicine are being used to help screen and manage patients in in-home settings to flatten the curve of the pandemic.

Patients who are mildly ill are encouraged to call-ahead to the emergency department, their physician’s office, COVID clinics or urgent care facilities if they believe they have symptoms consistent with COVID-19.  This approach helps to facilitate screening and enables either drive though testing or the office visit accompanied by the provision of PPE, and placement in  a treatment/isolation room to reduce exposure to other patients.

Many patients with mild illness, can be discharged home, but require frequent monitoring for progression of respiratory symptoms of the disease. Some hospitals opt to use telemedicine to facilitate care coordination post hospital discharge, to include the use of videoconferencing, peripheral devices (such as electronic thermometers, oximeters, blood pressure cuffs and even remote examination tools). Treatment plans may be adjusted based on the patient’s clinical condition.

There are no strict guidelines about which patients should be discharged with telehealth monitoring for COVID-19. Currently, those decisions are individualized and system and provider dependent. The CDC provides printable guidelines as a basic reference.

Remote patient monitoring is a covered service under Medicare and by a number of state Medicaid programs and commercial insurance plans.

Replacement of in-clinic in-person services:

Practitioners are rapidly transforming care delivery models including through the replacement of in-person, in-clinic visits with virtual care models provided to the home.   Medicare, Medicaid and commercial payers have enabled home as an eligible originating site, and telephone visits. Although HIPAA compliant communications services remain the gold standard for telemedicine services, at the declaration of the public health emergency, the federal Office of Civil Rights waived its enforcement authority to enable providers to connect with patients. In response, providers have begun to utilize their personal communications devices to enable video and phone visits with patients, when secure video connections are not readily available. The requirements for patient consent, and documentation in the record remain a requirement to support the billing of encounters. Medicare has expanded coverage of telemedicine services to include more than 80 additional services, in addition to eliminating the rural patient originating site restrictions, enabled video visits to the home as well as telephone visits.

Alternative treatment sites:

To manage surge, many healthcare systems and public health entities have expanded care through the establishment of alternative treatment sites, in addition to testing sites. Telemedicine services are a critical delivery mechanism to expand the workforce and to improve additional needed services.

eConsults:

Structured “curbside consults” between primary care, and specialty care providers and reduce the need for in-person visits. These services are covered by Medicare and a growing number of state Medicaid programs.

Project ECHO (Extension for Community Health Outcomes):

A number of COVID19 Project ECHO programs have been developed to provide video based didactic content along with case presentations in support of community providers.

For more information on the use of telemedicine and telehealth, we recommend Understanding Telehealth on AccessMedicine.

  1. Centers for Disease Control and Prevention. (2020, February 29). Interim Guidance for Healthcare Facilities: reparing for Community Transmission of Covid-19 in the United States.
  2. Gossen, A., Mehring, B., Gunnell, B. S., Rheuban, K. S., Cattell-Gordon, D. C., Enfield, K. B., & Sifri, C. D. (2020, in press). The isolation communication management system (iSOCOMS): A telemedicine platform to care for patients in a biocontainment unit. Annals of the American Thoracic Society.
  3. Virk, S. (2020, March 3). Coronavirus and telemedicine: How it can help practices and patients with communicable diseases, Medical Economics.
  4. Ackerman, S.L., Dowdell, K., Clebak, K.T., Quinn, M. and Shipman, S.A., 2020. Patients Assess an eConsult Model’s Acceptability at 5 US Academic Medical Centers. The Annals of Family Medicine18(1), pp.35-41.
  5. Komaromy, M., Bartlett, J., Zurawski, A., Gonzales-van Horn, S.R., Kalishman, S.G., Ceballos, V., Sun, X., Jurado, M. and Arora, S., 2020. ECHO Care: providing multidisciplinary specialty expertise to support the care of complex patients. Journal of General Internal Medicine35(1), pp.326-330.

Karen Rheuban, MD

Senior Associate Dean and Professor of Pediatrics, University of Virginia

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