By this time in current COVID-19 history, we all have a pretty good idea about some of the changes that are impacting clinical care. The fact is that the pandemic has pushed forward several clinical changes that were languishing in the background waiting for an opportunity to advance. Other than the abruptness of the transition, most of these clinical changes are positive and will endure into the future as both needed and practical.
In the middle of all the turmoil, the old idea of telemedicine has shot to the front lines of patient care. This methodology is more than simply giving advice over the phone. Doctors have always been available after hours to give advice or even manage care over the phone. Usually, there was no compensation because insurers did not value the service. The pandemic quickly demonstrated that telemedicine offers good value to patient care, especially for patients with chronic diseases such as diabetes or congestive heart failure.
In the early years (pre-2005) smaller hospitals with limited or no neurological coverage connected with larger, better staffed hospital centers for help in managing stroke patients. This clinical intervention was especially useful, helping ER doctors manage the use of TPA (tissue plasminogen activator) depending on whether a clot or a bleed was the primary cause of the stroke. Time is of the essence with this condition. Telemedicine cut through the time constraints and got appropriate care to stroke patients.
COVID-19 pushed necessity and imagination, which then became the only limits on using telemedicine in clinical care. A health system in New Jersey grew from zero telemedicine encounters to over 2,500 per month.[i] A busy ER in Kentucky connected non-emergency patients with a primary care doctor 445 miles away, maximizing resources and providing care efficiently.[ii] Progressive ideas followed the necessity of the times.
Primary-care doctors suddenly lost track of their patients due to the stay-at-home orders. CMS quickly and appropriately responded by removing restrictions on telemedicine by expanding the payment rate to the same compensation as an in-office visit. Practices suddenly reconnected with their patients and managed their chronic disorders, keeping them out of the emergency rooms and hospitals. Additionally, telemedicine preserved a modest income stream to sustain many practices while everything around them was shutting down.
Beyond the direct primary-care doctor-to-patient telemedicine connection, specialists’ use of this technology now opens small communities to the advantages of large health center expertise. Working with local providers the University of Missouri Network makes specialists available across the State with connections to remote doctors’ offices and clinics. Remote practitioners are trained in the specialty physical examination to increase mutual confidence of a good result on both ends of the process. Remote families appreciate receiving care through telemedicine with easier access to high-quality specialty care, less driving, less urban traffic, and less time off from work.[iii]
Remote or peripheral devices connected through the internet and Bluetooth are simply an extension of chronic care management and telemedicine. These devices increasingly create the opportunity of frequent, even daily monitoring rather than sporadic or episodic care through an office visit. An important clinical caution here is that these devices must be connected to and followed by a primary care physician, not an independent supplier focused on pushing more “stuff” out the door in order to bill Medicare or Medicaid. We cannot afford to repeat the DME fiasco.
Telemedicine is not a replacement for the clinical visit where important physical findings guide the care; for example, the foot and eye examinations in the diabetic patient. There is also the unmeasureable value of the physician’s touch that results from a skilled physical examination.
The keys to a successful telemedicine program are simple and practical. Payers must require the same standard of performance and documentation. Of course, the service should be paid for by all types of payers. Additional advantages are clear in reducing exposure to infectious disease for vulnerable populations. Missed appointments due to transportation problems are mitigated and patient satisfaction is a proven result. The technology can and should be used for patient education individually or in groups to potentially improve patient cooperation through better health literacy.
Nonetheless, keep in mind that the temporary, bug-induced telemedicine changes will need congressional action to make them permanent. We cannot assume that it will just happen. HIPAA still looms large as well as the need to add other practical providers such as speech therapy for stroke patients and other home-bound beneficiaries. Fraud and abuse guardrails remain a compelling necessity–remember DME.