As COVID-19 has disrupted every day life, telemedicine has been invaluable in allowing patient treatment without the risk of infection. This author details his experience with telemedicine, particularly in nursing homes and in rural settings, noting the technology can be a savior for patients and physicians.
Never in my lifetime have I seen such a disruption to our health care system as we wage the battle against COVID-19. Many of us transitioned to telehealth technology within a matter of days after lockdown orders started. When I last wrote about telemedicine, only a handful of providers used telemedicine. In a matter of weeks now, telemedicine has become a household phenomenon.
Both patients and doctors are getting used to the telemedicine technology. Just as necessity is the mother of invention, the COVID-19 pandemic and lockdown forced most of us to communicate with our patients by some means so we can keep them out of the emergency rooms and hospitals and keep them in their homes, the safest place right now during a pandemic like this one. A recent survey by the Texas Medical Association showed that 74% of physicians implemented telemedicine after March 1, 2020 in Texas. I am sure these survey results would be same if we surveyed our wound care practitioners all over the United States.
The Centers for Medicare and Medicaid Services (CMS) were quick to relax the rules so patients can be taken care of during these unusual circumstances. Never in my career as a physician have I seen so many regulatory rules lifted. HIPAA rules were lifted during the public health emergency, with the U.S. Health and Human Services (HHS) Office of Civil Rights (OCR) not penalizing physicians for noncompliance with HIPAA when servicing patients in good faith through common communication technologies like FaceTime or Skype.1 At the same time, CMS allowed use of the same billing codes as office visit evaluation and management (E&M) codes for telemedicine. During this public health emergency, rural and site limitations are removed. Telehealth services can now be provided regardless of where the enrollee is located geographically and regardless of type of site, which allows the home to be an eligible originating site. However, newly eligible locations will not receive a facility fee.
Why Telemedicine Will (and Should) Last Beyond COVID-19
I hope some of these changes will last in the post-pandemic period as both physicians and patients are getting used to the tele-visit technology now.
For me, telemedicine has been very helpful for the nursing home patients. We are able to do virtual wound care rounds with a wound care nurse at the nursing homes. I am able to get first-hand information on what patients are getting for their offloading in nursing home settings. I can talk to a dietitian, a therapist, or a medical director and truly provide a multidisciplinary care. I feel telemedicine is a great service for elderly patients who do not have to travel by ambulance to a clinic or another facility. They can be treated at the point of service and we can provide the same level of care.
It is interesting that once we started the telemedicine service, we started getting consults from a rural area where there are no wound doctors. Nurses from these rural areas were thankful that we could help them take care of their patients in their own homes with the help of home health nurses.
I feel that by the time this pandemic is over, telemedicine will become part of everyone’s practice. Patients who are less sick, patients who are working, busy parents with no babysitters, or patients who are traveling from afar will prefer telemedicine for follow-ups. Patients will have to come to the clinic if they require procedures and if patients do get really sick, they can be referred to the ER/hosptial. Post-surgery follow-up can also routinely be done through telemedicine now.
I feel telemedicine is a boon and a real savior. Because the pandemic disrupted health care so quickly, I feel there is an urgency to enhance the evidence for telehealth technology applications as clinicians and consumers expand its use in numerous areas. All my colleagues are now using real-time video consultations with off-site specialists in all fields such as family practice, internal medicine, cardiology, dermatology, psychiatry, behavioral health, gastroenterology, infectious disease, rheumatology, oncology, wound management, and vascular disease.
Primary care doctors are using tele-visit to screen COVID-19 patients and setting up a drive-through testing center. They are using tele-visits for counseling, medication prescribing and management, and management of long-term treatment for diabetes, chronic obstructive pulmonary disease, and congestive heart failure.
Best Practices for Telemedicine
I encourage doctors to look at telemedicine as a long-term strategy for their practice as telemedicine is here to stay. Here is what I have learned about telemedicine:
• Use a secure, encrypted technology that is HIPAA-compliant, execute a business associate agreement (BAA) with the vendor. A sample BAA for members is available at TMA’s HIPAA resource center: www.texmed.org/HIPAA.
• Before looking around for a telemedicine vendor, check if your own electronic health record system has telemedicine capabilities.
• Once the vendor is selected and if you are ready to sign the contract, you can get your contract evaluated free by TMA if you are a TMA member.
• Inform your liability insurance carrier that you will be providing telemedicine services with an effective date.
• The standard of care and documentation requirement for tele-visits is the same as for face to face visits.
• Physicians licensed in Texas are allowed to perform tele-visits only in Texas.
• It is also a good idea to create a triage pathway for your office. 1. Determine which patients are appropriate for telemedicine. 2. For elderly patients, coordinate your tele-visits at the time of the home health visit.
• You will need to create a workflow that works for your practice. In our practice, the secretary schedules tele-visits, creates the encounter, verifies insurance and collects copayment like any face-to-face patient.
The secretary also connects the patient just before their appointment and keeps them in a virtual waiting room so physicians’ time is utilized wisely.
Hope you find this information helpful. The resources below have more detailed information on telemedicine.
Jayesh B. Shah is president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. In addition, he is president of South Texas Wound Associates, San Antonio. He is also past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society.
1. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017; 377(16):1585–92.
2. American Medical Association. Digital health payment. https://www.ama-assn.org/practice-management/digital/digital-health-payment.
3. American College of Physicians. Telehealth coding and billing during COVID-19. https://www.acponline.org/practice-resources/covid-19-practice-management-resources/telehealth-coding-and-billing-during-covid-19. May 1, 2020.
3. Texas Medical Association. Telemedicine: getting started. https://www.texmed.org/uploadedFiles/Current/2016_Practice_Help/Health_Information_Technology/Telemedicine/COVID-19%20Telemedicine%20Getting%20Started.pdf. March 2020.
1. U.S. Department of Health of Human Services. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.