Next Steps for Chronic Illness Care After the Taskforce on Telehealth Policy (TTP) Report
Trisha Kaundinya, BS, MD/MPH candidate;1 Rishi Agrawal, MD, MPH2
Affiliations: 1Northwestern Feinberg School of Medicine; 2Associate Professor of Pediatrics (Hospital-based Medicine), Northwestern Feinberg School of Medicine
Telehealth experienced rapid adoption during the Covid-19 pandemic. Hence, the National Committee for Quality Assurance (NCQA), the Alliance for Connected Care, and the American Telemedicine Association (ATA) created a task force on telehealth policy (TTP) to elucidate its role post-pandemic. TTP identified no care overutilization and fewer no-shows to appointments in analyzing preliminary pandemic data, which were primary concerns regarding telehealth. Cost-related problems also caused resistance towards a telehealth transition, but TTP identified promising cost reduction mechanisms in telehealth through more transitional care management and lowered skilled nursing transfers.1 These findings are encouraging, but to leverage them in our health system, we must address telehealth specifically in the chronic illness population.
The TTP report already addresses patients with chronic illnesses in some ways. For example, concerning data flow, TTP championed remote patient monitoring to improve patient autonomy and reduce strain on caregivers. They proposed a pilot virtual medical home and Fast Healthcare Interoperability Resource (FHIR) shared care plan, which benefits those with routine and regular follow-up requirements.
TTP also advocated to remove originating site requirements, permit audio-only telehealth when it has proven to be useful, and consider technological access as a barrier to telehealth use—challenges which are all pronounced in the chronic illness population.2
Investment in Chronic Illnesses
Many existing initiatives for telehealth administration and reimbursement support episodic care that accountable care organizations (ACOs) manage, but those with chronic illnesses are perhaps best positioned to benefit from all that a telehealth transition can offer. Currently, almost one-half of the population has at least one chronic illness, and nearly 60% of all emergency department (ED) visits are for people with at least one chronic condition.3 There is currently an apparent mismatch between the CDC’s budget for chronic illness prevention, around $4 per person per year, and our spending on those with one or more chronic illnesses, which is about $8,000 per person per year.4
This mismatch coupled with an increased incidence of chronic illnesses means more preventable deaths and increased disability-adjusted life years (DALYs). It also means high costs when care for chronic illnesses is improper: A study found that fragmented care for chronic illnesses increased average care management costs by almost $5,000 over three years.5 Racial, geographic, and socioeconomic disparities in access to care and care outcomes are also most pronounced in the chronic illness population. From all of these perspectives, telehealth has the potential to revolutionize chronic illness care.
Instead of acute episodes that mandate brief in-person evaluation, effective chronic illness management requires a longitudinally connected care team. Telehealth in the form of RPM has shown to be useful. RPM is associated with reduced hospital admissions, nursing home admissions, ED visits, and improved preventative care use.6 The epicenter of chronic illness is moving away from the clinic and into the home, so the intersection of telehealth and home health care is a keystone to successful adaptation. Home health is also associated with reduced patient mortality and hospitalizations.7 The care continuity sought after in health systems managing patients with chronic illness depends on continued prescription access and thus discussion of how this changes in a virtual setting are also warranted.8
Given the great potential of telehealth to affect chronic illness management, we have articulated some of our telehealth policy and administration recommendations that follow TTP in this patient group.
Remote Patient Monitoring
Remote patient monitoring (RPM) is one of the most critical telehealth modalities for patients with chronic illnesses, especially as they get older. Many prefer to maintain their independence without requiring caregivers in facilities.
Earlier in the pandemic, an emergency rule expanded RPM use to new and established patients. This policy does not apply after the public health emergency ends according to the 2021 Physician Fee Schedule released by CMS. The rule needs to extend permanently post-pandemic.
Longitudinal care is one of the most significant challenges for patients with chronic illnesses, especially in rural areas with higher clinician turnover rates and lower numbers of providers. These patients would not be able to engage in telehealth and RPM in their onboarding to new providers without an in-person history and physical. The upfront convenience benefit of telehealth is lost when patients have to travel far and wait for care, and thus these patients are less likely to attend to their chronic illnesses. Patients with more complex chronic illnesses often cannot travel to establish a point of care with physicians in person and thus lose care connectivity from earlier clinicians.
The 2021 Fee Schedule mandates that in a 30-day time frame, providers can only bill once under CPT codes 99453 and 99454 for RPM independent of the number of devices patients use. Minimizing overuse of billing may be a driving incentive for this policy, but it disproportionately affects patients with multiple chronic illnesses who require many devices for their RPM. Even for patients with only one chronic illness, providers may need data from the patient’s pressure cuff, pulse oximeter, and glucose monitor, among other devices. Patients cannot be effectively managed by providers if only billed for RPM once a month. Inappropriate management of patients with multiple chronic illnesses has dire outcome and cost implications, so this requirement needs a revision that accounts for complex technology needs.9
The convenience afforded by telehealth goes hand-in-hand with the setting of home healthcare, which allows patients to sustain functionality and control over their activities of daily living. Home health has been associated with improved outcomes for patients with chronic illnesses long-term.7
Throughout the Covid-19 pandemic, CMS has generated several telehealth coverage waivers for providers, but reimbursement for home health continues to trail behind. Home health aides (HHA) can legally provide telehealth services. However, these visits cannot replace in-person visits (they do not count towards the low-utilization payment adjustment (LUPA) threshold) and do not receive reimbursement as a virtual visit. HHA providers could engage in multiple mediums of telehealth to meet patient care needs, but they would still need to meet the patient in-person to bill codes covered by Medicare and meet CMS mandates. The incentive for providers to continue to provide telehealth would decrease if it is not covered. They would also be increasing Covid-19 transmission risk to an often immunocompromised population while meeting in-person expectations.
Improving coverage of telehealth for HHA has important uptake implications. One population whose engagement in telehealth long-term is limited is senior citizens, who comprise most patients for HHA. The current payment scheme disincentivizes telehealth use by HHA, when they could facilitate onboarding in a sizeable chronic illness population. Some states are relaxing rules around Medicaid coverage for HHA provision of telehealth. Thus a nationwide coverage expansion should be available for all states to opt into permanently post-pandemic.
Medication adherence is a challenge for patients with chronic illnesses, especially patients with several chronic illnesses and complex care regimens. Increased adherence in this population is associated with decreased hospitalizations and ER utilization. Telehealth has a critical role in this relationship, as it can lower the additional burden of long travel and waiting times included in adherence regimens.
Opioid Use Disorders(OUD):
The 2021 Physician Fee Schedule states that through Section 3 of the SUPORT Act, effective January 1st of 2021, prescription of Schedule II-V controlled substances under Medicare Part D can be done electronically. Still, they are soliciting commentary regarding any exceptions. Recent studies have reported that Medications for Addiction Treatment (MAT) programs for those with OUD which involved telehealth had better outcomes than their in-person counterparts and that telehealth was a primary reason that patients stayed on MAT.10
When it is clear that telehealth utilization in counseling as well as the e-prescribing process improves outcomes for those with OUD, there should be permanent lifts on controlled substance prescribing restrictions. The variability in states’ decisions to modify controlled substance prescribing laws that mandate in-person office evaluation should also be mitigated by CMS to federally and permanently enable telehealth in e-prescribing MAT even after the pandemic.
The only major exception should be to physicians who work in emergent settings, which would delay or decrease the chance of the patient’s prescription filling. Emergencies for patients with OUD are often outside of typical pharmacy hours, so e-prescriptions are not successful and require the patient to return and a new prescriber would have to engage in care. The existing prescript would have to be canceled as well. Patients with opioid use disorders on MAT are at high risk of relapses when there are delays in their access to medications. In acute emergency settings, they must acquire their medication in a timely fashion and thus in-person issuing of prescriptions could be more efficient.11
Overall, the TTP emphasizes integration instead of devising a new telehealth infrastructure in many of their recommendations related to patient safety, quality measurement, and data flow. There is also promising preliminary telehealth data from the pandemic, but the gateway to sustainable change is effective management of the multidimensional chronic illness population in America. This population contains some of the oldest, most socioeconomically disadvantaged, least technologically involved, and most vulnerable individuals in our health system.
With the involvement of CMS, the potential benefits of a more connected healthcare system, improved patient outcomes, and lower acute episode costs can be amplified. CMS should modify RPM fee rules for patients with chronic illnesses, expand their reimbursement criteria for telehealth by home health, and enable open-ended e-prescribing requirements for MAT except for acute care settings.
Under Recognition of the Potential Role of Telemedicine to Speed Data Dissemination and Communication in Veterinary Medicine in the Netherlands
Jack Gommers, Dongen, The Netherlands, firstname.lastname@example.org
Telemedicine can enhance information exchange in veterinary care. It provides triage, and, of particular importance for this post, timely follow-up regarding results of laboratory testing of livestock. Through the use of a case history, the focus here is on the author’s frustration with the current lack of remote communication and the potential role of telemedicine to speed sharing of essential information regarding risks to human and animal health.
In practice, a farmer maintains dialogue with the veterinarian who visits at least weekly. If an unknown disease strikes and analysis and diagnosis remain unclear, samples, often from dead animals, are sent to the laboratory for additional testing. In the Netherlands, this is conducted by the Animal Health Service, which sometimes forwards samples to accredited laboratories for further analysis. Based on test results, prescriptions are issued for collective treatment of the livestock or individual animals via oral or injected antibiotics.
If, as was experienced here, there is an unexpected lockdown by a governmental agency on suspicion of feed contamination, it is essential to know the diagnosis that made this action necessary. It must be remembered that family and children are at risk of unintentional contact with contamination. For rapid decision-making and to ensure public health, this is where telemedicine can be used for timely sharing of data.
In spite of the lockdown of my farm, gaining access to essential data was denied, for unclarified reasons. The Dutch government simply refused to forward laboratory results from tests carried out on my own animals. After asking the European Commission for guidance, they indicated that as a livestock farmer, I was certainly entitled to the test results of my farm. Yet, my government continued to refuse!
Despite zero tolerance required in European directives, the Dutch government tolerates finite concentrations of hormonal contaminants and pharmaceuticals in Dutch food, exported or not. According to the World Health Organization, chemical contamination might lead to acute poisoning or long-term diseases, such as cancer. Foodborne diseases might lead to long-lasting disability and even death.1
Another problem is mutation of bacterial and viral pathogens, e.g., coronaviruses.2
Coronaviruses are a large family of viruses that mutate easily. It is known for decades that they can be present in pigs, chickens, and minks in areas of intensive livestock farming. SARS-CoV-2 is the most recent virus variant of the Corona type, with dozens of mink farms infected. Millions of these animals have been killed already, to eradicate this source of infection (also in Denmark, by the way). Furthermore, SARS-CoV-2 is reported to a limited extent in pigs, chickens, dogs, and cats.
Another well-known zoonosis is the Q fever that flared in the province of North Brabant (in the south of the Netherlands) in 2007. It resulted in dozens of deaths and hundreds of people chronically ill for life. Q fever is a bacterial infectious disease that is mainly transmitted to humans by goats. Hundreds of thousands of goats were killed in the Netherlands because of this outbreak.
Officials of the European Commission pointed out to the Netherlands that all described risks to human health are unacceptable. In a parliamentary debate on this subject, with the responsible Ministers of Agriculture and Public Health, it was concluded that the Netherlands is indeed not following European guidelines 96/22 and 96/23 /EG for public health.
It is not my purpose to debate unacceptable policies at a political level here. As a farmer “in the field” my focus is on the health of my animals and the health of my family and others, by minimizing contamination risks. To this end, recognition of telemedicine is of utmost importance, as a valuable tool to facilitate the instantaneous provision of critical information and achieve the objectives advocated by the European Commission.
Transforming Health Care in the Wake of a Global Pandemic
Tory Cenaj, Publisher, Telehealth and Medicine Today
Some of the world’s top leaders and influencers in healthcare delivery transformation and health technologies, including blockchain in health tech and telehealth, converged at the 4th Annual ConVerge2Xcelerate (#CONV2X) 2020 Symposium held virtually from November 10th-12th, to exchange perspectives and solutions to shortfalls in global patient care exposed by COVID-19. The theme of this year’s symposium TMT hosted was “US-World Health Transformation.”
Impact of COVID-19 on health care
The global COVID-19 pandemic showed how vulnerable healthcare delivery is to patients around the world. Healthcare systems in every country have been challenged – not only in treating patients with coronavirus, but in trying to maintain optimal care for non-COVID patients at the same time.
As a result, new advances in digital health technologies, including telehealth, blockchain, AI and others, are transforming patient treatment models on an international scale. What this event proved is that healthcare transformation, via technology and new global models for greater access and more efficient and effective delivery of healthcare services to patients, is much closer to reality than ever before.
Many of the sessions over the two-day event focused on two main topics: healthcare interoperability, digital health, adoption, scale and equity.
On Day 1 of the event, this topic was highlighted by speakers from the UK, India, North America and the European Union. Interoperability is the ability of different healthcare systems and processes to communicate and share information with other healthcare systems and processes, either within or across organizational borders, in order to advance the effective delivery of healthcare. The consensus was that patients will enable interoperability through trust – a pivotal facet of adoption and scale.
Technology players will have to continue to grow in partnership with healthcare systems, which will be required for both the systems and for consumers.
According to Keynote speaker, Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, “Digital health is a new reality that will bridge disparity and access to those with lower income and the underserved.” Other Keynotes from Teladoc Health and Mayo Clinic Digital Platform emphasized transforming health care with digital health and virtual care delivery systems, which would make care affordable and equitable, decrease disparities among income levels and geographies, and create global standards and regulations for citizens and health systems around the world.
But digital health is a broad term, one that encompasses several technologies, including telehealth, virtual care, and digital tools and services, and requiring integrations that make health care delivery broader, easier and more flexible.
A Keynote session titled, “Virtual Health: The Next Frontier for Healthcare,” with Alex Harris, Partner, McKinsey & Company and moderated by Lyle Berkowitz, MD, FACP, FHIMSS, CEO of Back9 Healthcare Consulting discussed he radical digitization of health care with supply and demand factored in. Healthcare has lagged behind other industries in terms of digitization. But on the consumer (patient) side, mindset and behavior changes have moved the needle on telemedicine visits, and it is projected that 60% of those over age 65 will avail themselves of this technology in the near future.
Physicians question the effectiveness of telehealth visits and financial compensation, and they wonder about adoption and when it will stabilize. Telehealth visits were high in April, but decreased, perhaps due to restrictions in movement as things shut down.
The challenges to adoption that still exist include funding and parity for certain services and long-term reimbursement. Fee-for-service vs. value-based is still unclear. So while providers are still wondering about financial implications, consumers are starting to feel more comfortable.
It is clear that this past year has presented both many challenges to healthcare delivery and opportunities for innovations. The manner in which health care is delivered is occurring at a time when traditional physical interaction between patient and provider has basically been a “cease and desist order” for the safety of both parties.
To learn more and get access to the agenda and program, visit https://conv2x-2020-ondemand.eventcreate.com/
For a top line introduction and select presentations visit TMT at https://telehealthandmedicinetoday.com/index.php/journal/ConV2X2020
Building Telemedicine into the Post-COVID-19 U.S. Health Care Delivery System
Stephanie J. Zawada, M.S.
Affiliations: Mayo Clinic School of Medicine and Science, Yale University Sherwin B. Nuland Institute, American Medical Students Association
During the COVID-19 public health emergency, interest in telehealth soared to an all-time high. Specifically, telemedicine, the delivery of clinical health care services to remote patients using telecommunications tools, is seen as the most promising mode of health care delivery in the near future, with investor capital flowing into telemedicine platforms.
Regulatory waivers provided by the Centers for Medicare & Medicaid Services (CMS), executive orders issued by state governors, and mandatory social distancing measures fueled the widespread use of telemedicine during the pandemic. Healthcare stakeholders should keep the following telemedicine issues in mind as we prepare for the 2020-21 flu season:
Today, the methodological frameworks for the clinical validation of digital health technologies are still being developed. Separately defining telemedicine and telehealth services is critical to ensuring patient safety and promoting innovation. If telehealth is regulated like telemedicine, innovation will be limited. (Think about the potential of requiring artificial intelligence to pass licensure exams to deliver care.) If telemedicine is regulated like telehealth, patient safety could be compromised. (Think about online surveys where you can fill out questions to get a lifestyle drug without a doctor’s prescription. A heart attack patient in the ER who does not have this prescription in his EHR might then be prescribed drugs that lead to harmful drug interactions.)
States should address licensure reform that allows out-of-state physicians to practice telemedicine with in-state residents. Many states temporarily implemented this approach for the duration of the pandemic. This would allow patients in rural areas with a physician shortage to access doctors in near-by states and enable patients in states without a world-renowned medical center to access telemedicine care rendered by top-ranked specialists.
Additionally, as rural hospitals face ever-increasing financial challenges, telemedicine reimbursement parity offers them an opportunity to restructure their services. Mercy Virtual Hospital is a blueprint for adapting the delivery of health care services to meet the needs of the digital age.
Business expensing for telemedicine is possible. For instance, technology investments for telemedicine practice, such as “software, hardware, or hosting fees”, may be deductible. Even 3D-printed medical devices may qualify for R&D tax credits. For telemedicine doctors using a home office, the “space and the equipment that [they] use to work from home are all part of [their] tax deduction…[as well as] part of [their] home’s utility costs, internet costs, and even mortgage” .
Telemedicine use amid COVID-19 outbreak: A global perspective
Affiliations: Md Azharuddin1, PhD, Mohammad Adil2, PhD, Prem Kapur3, MD, Pinaki Ghosh4, PhD, Manju Sharma2, PhD
1Department of Pharmaceutical Medicine, Division of Pharmacology, School of
Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
2Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia
Hamdard, New Delhi, India
3Department of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia
Hamdard, New Delhi, India
4Department of Pharmacology, Poona College of Pharmacy, Bharati Vidyapeeth, Pune, India
In December 2019, several unidentified pneumonia cases were reported in Wuhan, China, caused by β-coronavirus, a novel strain of coronavirus (2019-nCoV). On 11 February 2020, WHO officially announced “COVID-19” as the name of this new disease.1 It is steadily rising by human-to-human transmission and has confirmed 26,31839 cases worldwide, till April 24, 2020.2 The WHO declared the outbreak a global public health emergency on January 30, 2020.2 COVID-19 pandemic has put most of the countries under public health as well as economic strain.3 Several measures have taken by different countries to cope with COVID-19 outbreak. Now the global health crisis continues to escalate, telemedicine critically stepped into the spotlight in health care system to slowing the COVID-19 outbreak.
Telemedicine is the use of electronic information and telecommunications technologies including, videoconferencing, internet, store-and-forward imaging, streaming media, telephone calls and wireless communications. It promotes and improve the vast distances patient and clinical health care by the means of interactions between patients and clinicians or between two or more consulting practitioners.4 Additionally, interactions of telemedicine have a different role in patient care. Synchronous interaction, where patients and consulting practitioners interacted in real-time. It is a two-way communication using audio-visual technology (e.g., video call). It may use to diagnose a disease, and provide treatment. Asynchronous telemedicine not providing the direct patient care, the shared information can be reviewed and answered in a delay of time between patients and consulting practitioners (e.g., e-mail).4 It may use to provide a patient care and healthcare opinion.
As the COVID-19 contributing higher fatalities among immunocompromised people like chronic diseases and comorbidities, it can be used to avoid virus exposure by the means of reducing hospital visits.5 In addition to, it can reduce the risk of COVID-19 transmission among health care professionals those working tirelessly in the frontlines by keeping all the significant infected patients out of hospital. 5 Televisiting and teleconsultation can be used to triage more patients, screen and diagnose remotely.5
According to Infectious Diseases Society of America (IDSA), it also supports cost effective care by keeping patients to unlikely visit to emergency department and face to face consultations.6
In recent, due to wreaks havoc of COVID-19 virus, the Centers for Disease Control and Prevention (CDC) a Federal agency urging the public and healthcare professional to use telehealth programs for communication in an effort to reduce the burden of unnecessary emergency rooms and clinics visits.
The World Health Organization (WHO), CDC, as well as several state public health agencies have suggested that telemedicine service must considered as an essential part of healthcare provider in “strengthening the Health Systems Response to COVID-19” policy. In addition, according to a new WHO policy, within the adequate service delivery action, it should be considered as one of the alternative models for clinical services and clinical decision support.
A survey carried out among U.S. patients have shown that 84% are more likely to choose those providers who offers telemedicine. In Israel, a TytoCare’s telehealth solution has launched a TytoHomeTM kit to examine COVID-19 patients in quarantine wards, as well as to monitor patients in isolation stays and home quarantine.5
TytoCare’s partners is all set to emerged the solution and expanded their use in the US and Europe. In recent March 25, 2020, the American Medical Association (AMA) launches telemedicine during COVID-19 outbreak, where physicians and experts can discuss the several issues and share the experiences over the ongoing pandemics. Also, the Government agencies are associated with industry leaders in virtual care. Ro is a patient-driven virtual telehealth company launched a digital health clinic, now it became a part of the White House’s Tech Task Force for coronavirus, aims to be the patient's first call for all of their healthcare needs.7
On March 25, 2020, the Indian Ministry of Health and Family Welfare (MoHFW) with NITI Aayog and Board of Governors (BoG) Medical Council of India (MCI) launched the official guidelines for telemedicine practices to prevent transmission of virus.8 Advised all the registered medical practitioners and doctors to provide and support healthcare services remotely via phone or online communication consultation where citizen go on nationwide lockdown for 21 days. Under this consideration, doctors can write prescriptions based on receiving telephonic, textual or video conversations-chat, images, messaging, emails, fax and others.8
This is a crucial step for digital health, and the decision has been lauded by current digital healthcare solutions, who believed that this is the need of the hour especially when the world is facing unprecedented challenges with the coronavirus pandemic.
Furthermore, there are several online health services such as Practo, 1mg, Medlife, mFine, significantly stepped in online consultations during the COVID-19 pandemics, where 1mg claimed a 300% rise in e-consultations for flu and fever-related illnesses since the beginning of March 2020. The telecommunication received from across the country, nearly 600 cities and towns. In addition, Practo, an online doctor-consultation service reported that, it sharply increases in telemedicine calls after a week since the first confirmed case of COVID-19 in India.9 Additionally, the USA, Israel, UK, Nordics and France are amongst the leading countries with established telehealth providers, and their cumulative experience is helping to respond to the current situation.10
This study briefly addressed the global perspectives towards use of telemedicine, in order to deliver and ensure the patient health and safety of health care professionals. Therefore, all countries are suggested to use telemedicine during this pandemic and set up an infrastructure for the next inevitable, infectious disease, if emerge.
Sun Pharmaceuticals, India, for providing assistantship for this project under the joint collaboration for the Ph.D. programme with Jamia Hamdard, New Delhi, India.
Why Veterinary TeleHealth is Critical to Keeping Our Pets (And Ourselves) Healthy During - And After - the COVID-19 Crisis
Hannah Cheng Lau, DVM
I have been very lucky to work almost exclusively in the field of veterinary telemedicine for over a year. I see patients over video and phone consults for a myriad of issues that can be managed at home. Planning, implementing, and troubleshooting a well-rounded telemedicine program in our large 30-veterinarian hospital has been exciting, new, and intimidating for everyone involved. A year ago we had no idea how extensively the program would be put to the test with the public health crisis that is COVID-19. Telehealth has a whole new purpose in this new reality. We have realized that while trying to ride the wave of current events, many of our colleagues are just dusting off their surfboards - or even more concerning, are still sitting on the beach.
I believe strongly that telehealth is an essential organ in the veterinary beast - and it has been for years. Telehealth has always been a part of any veterinary business, and it happens every day in every practice around the world. Like any untrained muscle, it can be challenging and uncomfortable to intentionally strengthen it - but it has always been there. When I speak to my colleagues about telehealth, the first thing I remind them of is that they are already doing it. Granted, a big portion of this is done by paraprofessional staff: mainly client service representatives, veterinary nurses, and assistants. Teletriage and teleadvice is being regularly performed over the phone, either when the client first contacts the clinic, or as veterinary nurse consults. Continuing care is also done daily on the phone, through email, or with voicemail tag. All of these communications, when done well, take hours of employee time and require years of professional and on-the-job training. Although the medium of multiple phone calls and voicemails feels familiar and therefore comforting, they are inefficient to document, confusing for a third party to interpret, and difficult to monetize.
With the continuing effects of COVID-19 stretching out with unknown horizons into the future, likely resulting in a society that is forever changed, it is naive and perhaps negligent to assume life will return to “normal” and telemedicine will become a dying fad. COVID-19 has underlined the importance of telemedicine to the general populace by helping clients and providers socially distance and reduce unnecessary travel. However, this has always been and will continue to be a concern for many of our clients even without a worldwide health crisis. COVID-19 has opened all of our eyes to the dangers and anxieties of navigating the world as someone who is immunocompromised. However, those concerns will continue to exist for our community members who are battling illness, differently abled, do not have access to transportation, or are away from home. Human medicine has trailblazed this space already, and offering virtual doctor’s visits has become more and more accepted with readily observed advantages in convenience and patient access. Deeming telemedicine as unnecessary or too risky for practitioners is the coward’s way out of developing better care for the marginalized.
In addition to providing better care for clients, I have seen patients benefit greatly from well-utilized telemedicine. I am the first to agree that the physical exam is the cornerstone of good veterinary medicine, and telehealth must be used shrewdly and with careful judgement (just like every other tool in the veterinary arsenal). However, there are many common consults that fit beautifully into the virtual space. Very anxious pets can experience stress-free vet consults in their comfort zone, with no danger of canine scuffles in the lobby or losing an escape artist cat in the parking lot. Exposure to infectious illness in the hospital can be reduced. Without the adrenaline of the hospital and white coat syndrome, I can often get a more accurate picture of what the client is seeing at home. Behavioral issues, good husbandry techniques, new puppy education, mild/moderate skin issues, acute lameness, diarrhea, and many other common issues can be discussed at length and often successfully treated. To be abundantly clear - telemedicine is not the space for the lethargic or very painful pet, the intractably vomiting pet, or the nonambulatory pet, just as these cases are not to be handled solely over the phone. There are still issues that must be seen in the hospital. There is no escaping using good judgement, and there is never a one size fits all for every situation. Luckily, this is nothing new to the experienced veterinary practitioner.
I too am clinging to the hope that soon things will be “back to normal.” However, COVID-19 has opened our collective eyes to the many advantages of conducting telemedicine in a purposeful and intentional way - in which an effective medium is used, efficient and thorough documentation is maintained, and the client is charged at a fair rate for a practitioner’s undivided time and attention. Clients will expect us to continue to provide this service even when social distancing becomes less critical for the average community member. Many veterinary practices have realized that a well-established telehealth program increases efficiency, revenue, and client satisfaction. Necessity being the mother of invention, this era of unprecedented challenges is also the birthplace of triumphant problem-solving. A sure way to add to this pandemic’s staggering losses to humanity would be to emerge on the other side refusing to embrace new technologies and ideas in order to grow, both as a profession and as a community. That said, this is neither the first nor the last challenge we will face together as a field, and small-minded fear is not a new enemy. I have abundant faith that we will not allow it to guide us going forward, and instead choose to explore exciting new ways to relieve animal suffering and protect global health.
Telemedicine: From Green Eggs and Ham to Bread and Butter
Richard B. Sanders
Affiliations: American College of Healthcare Executives, Society of Hospital Medicine – (Former Section Leader for the Rural Hospitalist Section), American Telemedicine Association
As the COVID-19 pandemic presses upon the world, it has acutely changed our concept of social engagement, as well as the practice of medicine. The pillars of policy and regulation that have previously restricted the otherwise bright future of telemedicine and virtual health are cracking.
Penned by a self-proclaimed early adopter and advocate for telemedicine, this opinion piece offers four (4) considerations for turning telemedicine from “Green Eggs and Ham” into “bread and butter” in post-COVID-19 responses.
In “Green Eggs and Ham,” the popular children’s book by Dr. Seuss, a persistent yet unpersuasive Sam attempts to convince the reluctant Guy to try his favorite delicacy. But no matter whether on a boat or a train, in a house, or even in the company of his favorite animal, Guy is uninterested in sampling such a visibly unappealing meal. Yet Sam’s persistence pays off when Guy, in an attempt to get Sam to leave him alone, finally agrees to try the green eggs and ham. At that point, Guy realizes what he had been missing all along!
As an early evangelizer of telemedicine, I felt much like Seuss’ character, Sam. I started to point my healthcare career toward telemedicine and virtual health in 2007 when a visionary CEO looked to create new value for patients and caregivers. I immediately bought into his mission of technologically enabling the hospitalist workforce. This work propelled me into the world of innovation and advanced educational pursuits where I spoke to national and international audiences, obtained a doctoral degree, and published articles in the journal of Telemedicine and e-Health.
Over the years and after many odd hours and late nights of pioneering new territory in the heavily entrenched healthcare industry, I got the impression that those who had yet to see the efficacy of telemedicine viewed my physician friends, administrative colleagues, and me as dreamers. Like Sam, I persistently recommended solutions that if the hospital or physician would just simply try, they would find appealing and perhaps even transformational. I know others’ collective experience in being early adopters of telemedicine have been the same. Although initial resistance was the norm, once a telemedicine solution was deployed the organization was never the same.
As the COVID-19 pandemic presses upon the world, it has acutely changed our concept of social engagement, as well as the practice of medicine. The pillars of policy and regulation that have previously restricted the otherwise bright future of telemedicine and virtual health are cracking. Our fee-for-service system is buckling under the pressure of dramatic reductions in patient visits across the entirety of the healthcare industry, so much so that the opportunities for technology-enabled physician services are finally being realized.
Telemedicine stalwarts and newcomers alike are realizing in a matter of weeks what before now would have been an impossibility at worst, or taken years for adoption at best. To be clear, while I am an ardent supporter of telemedicine services, I readily acknowledge that it isn’t ideal for all health conditions, nor for every patient. If it were possible to have an in-person visit and personalized physician-patient relationship for all patients, that would be preferred. However, that isn’t practical, and we have new and exciting technological advances that help us provide modern medicine and deliver care in ways that wouldn’t be possible otherwise given the complexity of disease and the relative centrality of medical expertise.
So, in true carpe-diem fashion, we must collaborate now to ensure that we can reasonably and responsibly “hardwire” current gains for the ongoing success of such technology-enabled physician services. Below is a list, though certainly not exhaustive, as there are many unique aspects to consider for each medical specialty in order to enable a telemedicine post-COVID-19 response:
1. Make interstate medical licensing a permanent fixture and expand to all 50 states
The pandemic has further exposed the longstanding issue of maldistribution of healthcare provider resources across the nation. We need broader adoption of the existing Interstate Medical Licensure Compact. By making it easier for our medical professionals to practice across state borders, we would not only be better prepared for the next crisis, but also bring more healthcare options to patients now.
2. Establish professional billing parity
By establishing a consistent framework for billing parity, barriers to entry would be lowered and ultimately patients will win, as their own local doctors will have further incentive to digitally engage rather than be replaced by the well-funded national aggregators that lack a true sense of the provider/patient relationship.
3. Mandate standards for Electronic Medical Records (EMR)
A standard for EMR interoperability has long eluded our medical record system and would create further synergy between caregivers across the care continuum, allowing for improved coordination of care and workflow efficiencies between and among providers. This would ultimately keep a patient “connected” and safe from the harmful effects of communication gaps.
4. Payor and provider value-based care contracting
While this may seem contradictory to the second point above, payors and providers alike need to reach greater and broader alignment for value-based care across the spectrum. Doing so can lead to greater clinical and technological innovation that will benefit patients individually and as a population. It could potentially insulate healthcare providers from the downward economic impacts of fee-for-service reimbursement during a pandemic, or in other states of emergency that discourage or prevent the direct contact and volume-based touchpoints demanded by the fee-for-service model.
Over the years, I have increasingly appreciated this Niccolò Machiavelli quote: “The innovator has for enemies those who have done well under the old, and lukewarm defenders in those who may do well under the new.” I believe the new system is upon us and, if handled carefully, will reward all those who will embrace it.
And so, I invite all former telemedicine “enemies” to become friends, and “lukewarm defenders” to become champions, as what was once “green eggs and ham” to many caregivers may now be “bread and butter” necessary in our current times.
New York: Beginner Books. Seuss, Dr. Green Eggs and Ham. New York: Beginner Books, 1960.
Drake C, Zhang Y, Chaiyachati KH, Polsky D. The limitations of poor broadband internet access for telemedicine use in rural America: an observational study [published online May 21, 2019]. Ann Intern Med. doi:10.7326/M19-0283
Struminger BB, Arora S. Leveraging telehealth to improve health care access in rural America: it takes more than bandwidth [published online May 21, 2019]. Ann Intern Med. doi:10.7326/M19-1200
Whatsapp Neurology: Meeting the Challenges of Tel
Telehealth and Medicine Today ISSN 2471-6960 |
An Open Access Online Journal Published by Partners in Digital Health.
TMT is published under a Creative Commons Attribution-NonCommercial 4.0 International License.
TMT will also publish content in other products such as license editions of TMT and grant republication sublicense in journals around the world.
Owned and managed by Partners in Digital Health (PDH).
OUR PARTNERS & MEMBERSHIPS