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Telemedicine for Chronically Ill Patients during COVID-19

Ryan Spaulding, PhD, Vice-Chancellor of Community Engagement & Director of Telemedicine, Research Associate Professor, Department of Biostatistics, University of Kansas School of Medicine

Carol E. Smith, PhD, RN, Professor, School of Nursing and Preventive Medicine & Public Health, University of Kansas Medical Center

 

              Telemedicine is the use of videoconferencing to enable a healthcare provider to interact with patients who are at home in real-time. As restrictions on activities and closures of facilities increase on a nearly daily basis, telemedicine may be the best way to provide continuity of care, urgent care, social support, or meet other needs while limiting broader exposure of patients and healthcare providers to the COVID-19 pathogen.

Clinicians can use telemedicine to assess patient status
and remotely guide them in daily care, such as the team
shown above (on right) guiding the mother in changing
her child’s CVC dressing (on left).

Uses of Telemedicine

              Telemedicine can be used in many ways, but there are two general ways it can be best leveraged during this unprecedented outbreak. First, it can be employed to screen HPN patients who have concerns that they are exhibiting symptoms of COVID-19 or think they may have been exposed. Clinicians can quickly connect with a patient in his or her home; they can see and talk to each other, and the clinician can evaluate symptoms and recommend next steps.

              The second way telemedicine can be used is for providers to consult with their current HPN patients or non-coronavirus patients who have routine appointments scheduled or need some other clinical assistance, thereby limiting their broader exposure to others at this time and reducing clinic or hospital patient traffic. It is important to note that while the telemedicine video itself may not be needed to assess COVID-19 or manage other clinical needs, video is required at this time for telehealth reimbursement purposes per the Centers for Medicare and Medicaid Services (CMS), state Medicaid, and most private payers. Audio-only consults over the telephone are not reimbursed at this time by the insurers.

Expanding Telemedicine in Time of Need

              During this unusual time, many of the federal agencies and states are making special policy accommodations to allow for more telemedicine to be provided to both coronavirus patients and non-coronavirus patients. For example, CMS has temporarily eliminated the geographic restrictions for telehealth so patients will be covered by CMS regardless of whether they are in rural or urban areas. In addition, reimbursement for these services will be covered by CMS if the originating site is the patient’s home—it doesn’t have to be from one clinical setting to another at this time. (For billing purposes, the process for telehealth consults is the same as for an in-person visit except “place of service” is coded a 2.)

              In addition to CMS, the Office of Civil Rights (OCR) within Health and Human Services (HHS) has announced it will waive any potential penalties to providers who use non-HIPAA compliant video applications to provide telehealth services to patients. This means that some common video programs like Facetime, Skype, Google Hangouts, and others can now be used for providing telehealth during this crisis. The guidance indicates that telehealth services that are provided in good faith and with all other available best practices will not be penalized. However, providers should notify patients of the potential for security risk if one of these non-healthcare video applications is utilized. This policy is effective whether telehealth is used for coronavirus patients or not.

              Most of these platforms are simple to use with just a little practice. Often, they only require a patient’s email address, telephone number, or username to connect directly to the patient on their home computer, iPad, or even Smartphone. With several of the cloud-based web conferencing systems such as Zoom or GoToMeeting, a date and time is selected for the appointment and a link is emailed to the patient. At the time of the connection, the patient simply clicks the link.

              For other apps, like Facetime, the process may be even simpler. If the provider and patient both have an Apple device, a provider can simply open the Facetime app, select the patient’s contact phone number, and tap it. The call will instantly be made to the patient’s device. Clinicians and their staff will just need to spend a little time to determine what platform might already be available in their organizations and whether it will work across devices and brands, or if a combination of platforms may be needed.

              Further, on March 18, 2020, it was reported that HHS will permit all medical care providers to practice across state lines, regardless of their state license, in order to treat more coronavirus patients. No other details have been provided as of press time and it is unclear how state licensing boards will implement this policy. Providers are strongly encouraged to check with their state boards before providing telehealth across state lines until more detail is provided in the coming days. However, with this and the other unprecedented accommodations that have already been made, it is possible that HPN patients may be able to access needed services via telemedicine no matter where they live.

Navigating the Logistics

              There are multiple models for incorporating telemedicine visits into the clinical setting and workflow. One common model, particularly for lower volume, is for providers to conduct telehealth visits in-between their regular in-person patients or when they have patient no-shows. These are sometimes independently initiated by the provider and conducted right from his or her office, thus freeing up exam rooms. For higher volume, this model can also be used, or a block of time can be set aside in which patients are scheduled. In this model, more coordination with the office staff is needed to schedule the patients and get them connected for their virtual visits to maximize clinician efficiency.

              In any scenario, while some of the technical HIPAA requirements have been modified during the COVID-19 pandemic, practitioners should still observe other privacy best practices, such as having a private room from which to conduct the telemedicine consult; informing the patient of the potential for reduced security if using a consumer-level video application; and ensuring that all security settings on the app are maximized. In addition, while not always possible on all devices, it is suggested that a high quality or high definition (HD) camera be used; and, if using a desktop or laptop computer, that an internet cable be used instead of Wi-Fi. These safeguards will help ensure the best audio/visual experience for HPN patients and their providers.


Benefits of Connecting

              The other important way, in this time of social distancing, that telehealth connections have been shown to be significant are in connecting groups. In our research, we have multiple professionals meet with a patient and their family. Most often these professionals report how they have better understanding of the complete plan for the patient across all the providers. Also, individual patients can be assessed privately and the family members separately, to obtain “two sides” to the symptom story.

              Our other research outcomes are being able to “see” depressed signs and symptoms, and even judging suicide ideology. Lastly, we have published other findings on our successes with groups of patients (especially teens and young adults) in discussion groups over telehealth. These populations have enjoyed using their own and loaned iPads to “Zoom” in to their healthcare providers. This allows providers to give out the correct information needed for these young people to adjust to and correctly manage their medical regimens. In our research across the age range of HPN patients and their families, we see great benefit from groups coming together.

              In our studies with patients meeting using iPads’ audio-visual capabilities, we use guidelines for social media and health safety: encouraging patients to NOT share any health information and to not meet in person anyone they have only met on the internet. We also encourage that no medical advice be given. The evaluations of such group sessions have consistently been that it is helpful to meet by distance others who have similar situations. Medical centers typically have encrypted and fire-wall protected telehealth devises or connections; we caution against using commercial devises so that patients’ privacy is protected.

 

Scripts for Controlled-Substances During COVID-19

Shawna Wright, PhD, KU Center for Telemedicine & Telehealth, University of Kansas School of Medicine

Recently the Drug Enforcement Agency (DEA) published guidance relating to the COVID-19 public health emergency, which includes an exemption to the federal Ryan Haight Act’s requirement to conduct an in-person exam before prescribing controlled substances via telemedicine. In response to the public health emergency, DEA-registered practitioners may now issue prescriptions for all Schedule II–V controlled substances to patients without first conducting an in-person medical evaluation, providing (1) the prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice; (2) the telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and (3) the practitioner is acting in accordance with applicable federal and state law. More details at www.deadiversion.usdoj.gov/coronavirus.html.
Editor's note: We have heard of delays with scripts due to skeletal staffing in some offices.


LifelineLetter, March/April 2020


This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

 

Updated in 2015 with a generous grant from Shire, Inc. 

 

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.
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