Due to the COVID-19 pandemic, many physicians, physician assistants, nurse practitioners, and other health care providers (HCPs) transitioned their clinical practice to telemedicine in the last few weeks. As recommendations from the Centers for Disease Control (CDC) cautioned that older adults, 65 years or older, were at a higher risk for illness with the virus, the Centers for Medicare & Medicaid Services (CMS) “broadened access to telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a health care facility.” This was allowed on a temporary and emergency basis through the 1135 waiver authority and Coronavairus Preparedness and Response Supplemental Appropriations Act. Prior to the pandemic, the only Medicare beneficiaries that qualified for telehealth services had to be seen in an originating site in two circumstances: 1) a county outside the Metropolitan Statistical Area (MSA) or 2) a rural Heath Professional Shortage Area (HPSA) in a rural census tract. Examples of originating sites include a physician’s office, hospital, or skilled nursing facility (SNF).
This was a boon to all health care providers because, as we all know, illness does not stop for a pandemic. I work at a heart hospital in Oklahoma City, which employs approximately 90 cardiac and vascular surgeons, interventional cardiologists, electrophysiologists, non-invasive cardiologists, anesthesiologists, and pulmonologists. In addition to serving the greater metropolitan area, we have more than 60 outpatient clinics across the state of Oklahoma, which is largely rural. In the locations where do we not have clinics, it is not unusual for patients to drive 2 to 4 hours for a clinic visit in one of our two city or rural locations. Through all our hospital-based and rural clinics, we serve approximately 100,00 patients.
As there became an urgency to limit patient flow in our hospital due to COVID-19, our top-notch IT department quickly enabled our electronic medical record (EMR) to communicate with a telemedicine platform which met all HIPAA, GDPR, PHIPA/PIPEDA, & HITECH requirements (there are various telehealth app and websites such Doxy.me, Zoom, and Google Hangouts to name a few). CMS will currently pay for a telemedicine visit with an established patient and states on their website, Human and Health Services (HHS) “will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.” Many commercial insurance companies are following suit, including one of the largest payors in Oklahoma, Blue Cross Blue Shield, who has waived in-network co-pays for telemedicine.
My typical clinic day as an electrophysiologist (EP) consists of 4 to 6 new patients and 20 established patients. My medical assistants and staff converted my existing clinic into a telehealth clinic by calling our patients and seeing if they had smartphone capabilities (iPhone, Android, iPad, laptop for example). Through our EMR, we switched the outpatient office visit to telemedicine and sent the patient a text with a link to accept our invitation to a telehealth visit. To ease the transition, I only did telehealth visits with established patients. We also advised patients that if they were able, to weigh themselves and obtain a blood pressure and pulse at home with a blood pressure cuff on the day of their visit.
On the clinic day, my medical assistant called the patient 10 minutes prior to the appointment and inputted the vital signs, review of systems, and medication reconciliation into the EMR. Once complete, the patient received a text with a link to enter my “virtual waiting room.” I also received a text stating that the patient was ready to be seen. I clicked on the link on my laptop to start the call, and we initiated a video telehealth visit. I did twelve telehealth visits during my first clinic, and the success was amazing. Short of laying hands on them, I was able to truly assess how they were doing and deliver lab and test results. As an EP, I discussed their recent device transmissions, monitor results, and arrhythmia symptoms. Dare I say the visit was more intimate and, as a colleague of mine noted, “cozy.” We were seeing these patients in their homes, where they have let their guard down and are most vulnerable. Seeing them in their natural environment helped me be a better clinician as I had more insight into their home life. Many spoke not only about their clinical symptoms but about their concerns about COVID-19, both the health and financial implications. Most importantly, our patients were so grateful that they had the ability to communicate with their physicians in a time of isolation.
Oklahoma has 77 counties, of which 76 are designated HPSAs. Even though our practice has extensive outreach, we could ultimately serve more patients with these new telemedicine rules, especially after the pandemic subsides. There are still many challenges posed in telemedicine, including maintaining a patient’s privacy, the security of protected health information, and making appropriate plans of care consistent with an in-person visit. In Oklahoma alone, there will have to be a major expansion of broadband infrastructure to make what I am proposing even feasible. While not all fields of medicine are suited for telehealth and I will continue to see new patients in person to establish a trusting relationship, our own hospital’s telehealth experience with cardiovascular patients has been quite a feat. HCPs across the country have been like the Autobots from the Transformers: we “transformed and rolled out” with telehealth when our patients were being “attacked” by the coronavirus.
The innovations in telemedicine and relaxations of CMS’s policies have created an atmosphere in which health care providers are thriving and doing what we do best: taking care of our patients. Health care providers should implore the Department of Health and Human Services (HHS) and the Trump administration to continue the current CMS telehealth guidelines after the calamity has resolved. They should set an example for commercial insurance companies and lead the way for facilitating patient care. For a large majority of patients, this is the future of medicine, and I foresee this technology becoming mainstream and more widely expected by patients, insurance companies, and used throughout the medical field. This is the new reality in our current dystopian world. And telemedicine is here to stay.
Subha Varahan is a cardiologist.
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