Tele Medicine During Pandemic and Beyond Anna K. Abramson MD - PowerPoint PPT Presentation

Tele ‐ Medicine During Pandemic and Beyond Anna K. Abramson MD Associate Professor of Clinical Medicine University of California, San Francisco Tele ‐ Primary Care Physician San Francisco VA

Objectives and Disclosures  Disclosure:  Co ‐ founder of Medicine of Cycling, (non ‐ profit)  Objectives:  How to tele ‐ health  Benefits and challenges  Patient trends  Checklists  Costs, platforms

Quick Poll • Were you doing telemedicine prior to the Covid ‐ 19 pandemic? • Are you doing telemedicine now? • Do you intend to continue telemedicine after the pandemic? • Do you want your care through telemedicine?

Introduction Prior to 2017 Hospital medicine Home/facility visits San Francisco VA started rural telemedicine program in 2017

Goal:  Meet major provider shortages Challenge: 450kl  Major infrastructure  Training for staff on new equipment  New protocols  Resistance from patients and staff Opportunity:  Revitalized clinics  Health equity to rural veteran communities

Never Let a Disaster Pass you by…

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) “Effective March 6, 2020, the Health and Human Services (HHS) Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID ‐ 19 nationwide public health emergency.” For more information: https://www.hhs.gov/hipaa/for ‐ professionals/special ‐ topics/emergency ‐ preparedness/index.html

Center for Medicare and Medicaid Services Waiver Section 1135 https://www.cms.gov/Outreach ‐ and ‐ Education/Medicare ‐ Learning ‐ Network ‐ MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Billing Rules CMS • Effective March 6, 2020 and for the duration of the COVID ‐ 19 Public Health Emergency, Medicare will: – Make payment for professional services furnished in all areas of the country in all settings. – Consider synchronous visits with telephone and video same as and paid for at the same rate as regular, in ‐ person visits. – Leave it to providers to consider reduced or waived cost ‐ sharing for telehealth visits paid by federal healthcare programs. • HHS will not conduct audits to ensure that a prior relationship existed for claims submitted during this pandemic. https://www.cms.gov/newsroom/fact ‐ sheets/medicare ‐ telemedicine ‐ health ‐ care ‐ provider ‐ fact ‐ sheet

Asynchronous and Brief Check ‐ Ins • Requires pre ‐ established relationship with the patient. • Patients have to initiate communication with their doctors through online patient portals. • Physicians will be remunerated through several CPT codes for ongoing communication. • Brief synchronous check ins are 5 – 10 minutes and have to be stand alone, not part of a follow up from prior 7 days or resulting/predating procedure or emergency visit in 24 hours. https://www.cms.gov/newsroom/fact ‐ sheets/medicare ‐ telemedicine ‐ health ‐ care ‐ provider ‐ fact ‐ sheet

Significance of CMS Waiver Section 1135 • Insurance companies often follow CMS changes for billing • Prior to this waiver Medicare billing for telehealth applied on a limited basis: – patients in designated rural area – care administered in clinic, hospital, or other designated medical facilities – limited conditions such as stroke

Interstate Medical Licensure Compact https://www.imlcc.org/

Objectives: Check Point  How to tele ‐ health  Benefits and challenges  Patient trends  Checklists  Costs, platforms

Tele ‐ Health Opportunities Video visits to patient in their “home” environment: • Outreach to rural, traveling, or high risk patients • Seeing the home or current environment • Preventing some ED and Urgent Care clinic visits • F/U wound healing, MSK injury reassessment • Follow up after injury, ER visit, hospitalization, or surgery • Increased access to specialty consultation • Joint specialty appointments • Bedbound/on hospice/in a long term care facility patients • Delivering a difficult diagnoses or sensitive test results • Group, family, multidisciplinary appointments

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Tele ‐ Health Opportunities Patient in the clinic, ER, ICU, inpatient: • Allow more face to face time with each patient, “return” to bedside without donning/doffing PPE • Minimize nurses having to go in and out of rooms to communicate with patients (can pop in over video) • Allow providers to see mix of F2F and telehealth patients • For patients who may need to be seen by multiple specialists on the same day, can be seen in one area but not requiring multiple rooms or nurses to re ‐ room the patient, then send the patient for any studies which cannot be done in the same room (labs, radiology) • Specialty consultation at bedside with opportunity for multidisciplinary collaboration • Capability for family meetings

Benefits to Patients • Decreased COVID exposure • Avoid travel to clinic and in ‐ clinic wait • Maintain relationship with PCP/specialist while training or travelling • No need for masks and PPE • Easier communication for patients who lip read due to hearing loss or language discordance • Provider can type information into the chat box – patient instructions – names of OTCs you want patient to get • Can share a screen with a patient to show test results, images, exercises, anatomy

Provider Benefits to Virtual In ‐ home Visits • No waiting rooms • No space limitations • Flexible schedule • Practice from anywhere • Can supervise trainees • No PPE donning/doffing • Follow patient through travel, virtually

Telemedicine Challenges For Providers For Patients  Technology  Technology  Tech savvy  Tech savvy  Physical exam  Physical exam  Limited diagnostic  Trust and relationship therapeutic procedures  Efficiency  Cost  Licensure

Objectives: Check Point  How to tele ‐ health  Benefits and challenges  Patient trends  Checklists  Costs, platforms

Source: Ateev Mehrotra et al., “The Impact of the COVID ‐ 19 Pandemic on Outpatient Visits: A Rebound Emerges,” To the Point (blog), Commonwealth Fund, May 19, 2020. https://doi.org/10.26099/ds9e ‐ jm36

Large Institution Case Study Types of Visit 10/20 ‐ Equipment available to patients and staff ‐ Staff trained ‐ Infrastructural needs solved https://app.powerbigov.us/Redirect?action=OpenApp&appId=59f0dac1 ‐ 303f ‐ 48c7 ‐ 97c8 ‐ 4440452d78be&ctid=e95f1b23 ‐ abaf ‐ 45ee ‐ 821d ‐ b7ab251ab3bf

Medicine Specialty Modality Breakdown https://app.powerbigov.us/Redirect?action=OpenApp&appId=59f0dac1 ‐ 303f ‐ 48c7 ‐ 97c8 ‐ 4440452d78be&ctid=e95f1b23 ‐ abaf ‐ 45ee ‐ 821d ‐ b7ab251ab3bf 23

Surgical Specialty Modality Breakdown https://app.powerbigov.us/Redirect?action=OpenApp&appId=59f0dac1 ‐ 303f ‐ 48c7 ‐ 97c8 ‐ 4440452d78be&ctid=e95f1b23 ‐ abaf ‐ 45ee ‐ 821d ‐ b7ab251ab3bf 24

Mental Health Modality Breakdown https://app.powerbigov.us/Redirect?action=OpenApp&appId=59f0dac1 ‐ 303f ‐ 48c7 ‐ 97c8 ‐ 4440452d78be&ctid=e95f1b23 ‐ abaf ‐ 45ee ‐ 821d ‐ b7ab251ab3bf 25

Objectives: Check Point  How to tele ‐ health  Benefits and challenges  Patient trends  Checklists  Costs, platforms

“Webside” Manner  Office private and uncluttered  Optimized lighting bright but not originating behind provider  Minimal extraneous noise  Professional dress top to bottom  Look at the camera instead of the patient on the screen SFVA National VVC training slides

New Telehealth Visit Protocol • Pre ‐ round to improve rapport • Ask and document patient’s location for emergency plan • Who else is in the room • Permission to discuss health information over modality Discuss video and audio technology contingencies with patient • Get current phone number at beginning of visit • Use phone in event of loss of audio while continuing to use video • • Outline to guide visit in new setting to keep the visit on track – Summarize past visit complaints – Ask about interval events (falls, mood, major health or social changes) Prepared check lists for specialty or type of visit – • Aftercare discharge instructions

Tele ‐ Medicine Hardware Version • Map clinic workflows • Relationship build with staff • Establish HIPAA compliant communication workflows for: Scheduling • Urgent patient needs • Changes in patient or staffing • Rooming patients • Concerning findings • Emergency management • • Schedule longer visits to accommodate: Rooming • Technology malfunction • Relationship building with patient • • Establish HIPAA compliant document workflow for: Wet signatures • Official signatures •