TeleMedicine Factors To Consider During A Public Health Emergency

By Paul Murphy and Dr. Jonathan Savage

TeleMedicine is rapidly gaining significant attention due to the current worldwide crisis and the immediate need for innovative delivery of care. For this discussion, “telemedicine” represents all references to telehealth, virtual care, virtual visit, digital health, and mhealth.  For the provider-to-patient model, the following is an overview of key items to consider in a disaster or public health emergency.^1,2    

Depending on the resource that is consulted, telemedicine may involve any of the following: telephone conversations, secure texting, on-line chats through a platform or web browser, asynchronous (store and forward), synchronous (real-time audio and video), and remote patient monitoring (RPM). ³ The provider’s patient population and clinical needs will partially influence the model that is used. The following provides a summary of each.

Telephone call: This is considered by some to be a form of telemedicine. A phone call is an example of audio communication only. A patient may prefer to use this versus other options. 

Secure Texting, Secure On-line chat, Instant Messaging: These platforms are currently being used to support communications between a provider and a patient. It is reported that more than 80% of physician practices are using secure communication platforms among providers, patients, and family members. ⁴ During times of a public health emergency, these can be valuable communication tools to compliment the patient’s overall care.     

Remote patient monitoring (RPM): This model allows a provider to leverage technology to monitor their patient on an on-going basis. Depending on the technology vendor, peripherals, such as blood pressure cuff and pulse oximetry, can be included. Health data, such as blood sugar, blood oxygen levels, and electrocardiograms can be monitored. The provider may also be able to define certain clinical criteria to trigger alerts while RPM is in progress. This is helpful in alerting a provider to early patient triggers and potentially allowing for the patient to be managed out of the hospital setting. ^5,6     

Store & Forward (asynchronous): This is the interaction between a healthcare provider and a patient involving technology that is not real-time and supports the exchange of files, such as pictures. Examples include a picture of lesions from the patient’s skin or when a patient takes a picture of their “sore throat” using their smart phone. Depending on a provider’s practice, asynchronous telemedicine may be sufficient. ⁷ 

Real-time audio video (synchronous): This allows for real-time audio-video communication between the provider and patient. In a rapid triage or crisis situation, this model can be used to visualize the patient and determine if assessment and/or treatment in a hospital setting is warranted. Depending on the technology that is used, peripherals can be included. For providers and patients, synchronous telemedicine can be accomplished using a smart phone, tablet, or personal computer that is equipped with a video camera and speaker. ^8,9    

What device to use? In a provider-to-patient model, telemedicine devices (e.g. hardware) can include smart phones, tablets, and personal computers. Peripheral devices, such as stethoscopes and wearables, can also be used. 

What Software/Platform to use? There are multiple telemedicine software or platforms options. During a crisis situation, if your practice has an existing platform, changes may not be necessary. If, however, your practice does not have a platform, or, if your current platform’s capacity is exceeded, there are options to consider. In a disaster situation, and depending on state and federal officials, rules and regulations may be loosened thereby allowing for the use of platforms that are more “social”, such as Facebook, Skype, and Zoom. Platforms such as these support texting, chat, and real-time audio-video interactions. Providers should note that if a social media platform is used during a crisis, once the crisis has concluded that providers may need to stop using the “social media” platform and select a platform that is (more) HIPAA compliant. ^10,11     

In addition, in a disaster or crisis situation, regulations may be temporarily adjusted thereby allowing providers to use their personal device (e.g. personal smartphone texting app) or temporary telemedicine solution in an effort to support the delivery of care. ^10,11       

Protected Health Information: A majority of today’s telemedicine models and technology vendors address the Health Insurance Portability and Accountability Act (HIPAA). The enforcement of HIPAA regulations may be loosened in disaster/crisis situations to support the use of technology by providers to quickly assess patients. ¹⁰      

Connectivity: TeleMedicine can be performed using cellular, satellite, and Internet connections. Internet connections may be wired or wireless (WiFi). Depending on the patient’s or provider’s location (e.g. rural area with limited connectivity), the quality of the synchronous connections may vary. Because asynchronous telemedicine is not real-time, connectivity is not as critical.      

Provider reimbursement: Reimbursement for telemedicine sessions varies by service line, payer, and by state. Parity, or the ability for a provider to be reimbursed for telemedicine session equal to that of an in-person visit, varies. In a disaster or public health emergency, the government may direct payers to reimburse providers for services provided via telemedicine that normally would not be reimbursed. ^12,13      

Provider licensure: Similar to providing care in-person, when providing care via telemedicine, a provider must have a license in the state where the patient is located. The Interstate Medical Licensure Compact (IMLC) is voluntary fast-track path that allows for providers to be licensed in multiple states. Not all states recognize the IMLC. In the case of a public health emergency, regulatory and/or state licensing agencies may waive traditional licensure requirements. Measures such as this support efforts to have a sufficient number of healthcare providers that are available to provide care. ^14,15      

Patient fee (Beneficiary fee): Depending on factors such as the patient’s insurance, the state where the patient is located, the payer’s (insurance) policy, and nature of the telemedicine session, a patient fee may be required. In the case of a crisis, the patient fee may need to be removed as it otherwise could be a barrier to accessing care. ¹⁶     

Patient location:  There are rules and regulations regarding the patient’s location and which service lines can be provided via telemedicine. In cases of a crisis, these regulations may be adjusted to accommodate the delivery of care regardless of the patient’s physical location. ^10,13        

Documentation: Many telemedicine vendors offer telemedicine clinical documentation platforms. Telemedicine documentation output ranges from faxes to integration into a practice’s existing electronic health record (EHR) / electronic medical record (EMR). If a provider’s practice has an EHR and is preparing to use telemedicine but the telemedicine system does not include an EHR, an option to consider is to continue using the practice’s existing EHR. ¹⁷     

Patient consent: Traditional telemedicine models may include the use of a written consent prior to a telemedicine session taking place. In a public health emergency, the traditional approach may be modified to where a patient’s verbal consent is sufficient. The provider then documents that the patient provided verbal consent. ¹⁸      

Ongoing changes: As public health emergencies evolve, the rules, guidance, and business models related to telemedicine will continue to be revised to support the delivery of care. Providers should reference the most recent regulatory and legal guidance as provided by various entities. ^19,20      

Author bios:

Paul Murphy, MS, MA, Paramedic, has been involved in healthcare for 15+ years, including clinical and leadership roles. His virtual care experience includes working for a leading virtual care vendor and large healthcare system with a mature virtual care / telemedicine program. He has published articles in a variety of healthcare journals and is on the State of Colorado’s Office of eHealth Innovation’s Telehealth and Broadband committee.

Jonathan Savage, DO, is a practicing physician. He is the founder / CEO of Care on Location, is on the State of Colorado’s Office of eHealth Innovation’s Telehealth and Broadband committee, and is the Vice Chair – mHealth, Technology, & Distance Learning Group at the American TeleMedicine Association (ATA) as well as the Chair of the Advancing Telehealth for Medicaid Populations Committee at the ATA.

References

1. eVisit® Telemedicine Solution. 2018. The Ultimate Telemedicine Guide. What Is Telemedicine?https://evisit.com/resources/what-is-telemedicine/

2. Hollander, J., Brendan G. Carr, B.2020. Massachusetts Medical Society. The New England Journal of Medicine. Virtually Perfect? Telemedicine for Covid-19. https://www.nejm.org/doi/full/10.1056/NEJMp2003539

3. The Center for Connected Health Policy. 2020. About Telehealth. What is TeleHealth? https://www.cchpca.org/about/about-telehealth

4. Donovan, F. 2020. Xtelligent Healthcare Media, LLC. HealthITSecurity.com. Mobile News: Secure Texting Becoming 1st Choice for Sending Healthcare Data. https://healthitsecurity.com/news/secure-texting-becoming-1st-choice-for-sending-healthcare-data

5. McGrail, S. 2020. Xtelligent Healthcare Media, LLC. mHealthIntelligence. Remote Monitoring News: 88% of Providers Investing in Remote Patient Monitoring Tech. https://mhealthintelligence.com/news/88-of-providers-investing-in-remote-patient-monitoring-tech

6. The Center for Connected Health Policy. 2020. About Telehealth. Remote Patient Monitoring (RPM).

https://www.cchpca.org/about/about-telehealth/remote-patient-monitoring-rpm

7. The Center for Connected Health Policy. 2020. About Telehealth. Store-and-Forward (asynchronous).

https://www.cchpca.org/about/about-telehealth/store-and-forward-asynchronous

8. The Center for Connected Health Policy. 2020. About Telehealth. Live Video (synchronous).

https://www.cchpca.org/about/about-telehealth/live-video-synchronous

9. Hennick, C. HealthTech. 2020. Digital Workspace. The Role of Telehealth in Disaster Recovery. https://healthtechmagazine.net/article/2019/08/role-telehealth-disaster-recovery 

10. Shieber, J. 2020. Verizon Media. Tech Crunch. Administration expands telemedicine for Medicare and encourages health plans to boost offerings. https://techcrunch.com/2020/03/17/administration-expands-telemedicine-for-medicare-and-encourages-health-plans-to-boost-offerings/ 

11. HHS Headquarters.2020. U.S. Department of Health & Human Services. OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.

https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communicastions-during-the-covid-19.html

12. HIT Consultant Media. 2020. 6 Coronavirus (COVID-19) Considerations for Telehealth Providers. https://hitconsultant.net/2020/03/13/coronavirus-covid-19-considerations-telehealth-providers/#.XnJaRKhKhPZ

13, Miliard, M. HealthcareITNews. 2020. Global Edition. Telehealth. Trump administration expands Medicare telehealth benefits for COVID-19 fight. https://www.healthcareitnews.com/news/trump-administration-expands-medicare-telehealth-benefits-covid-19-fight

14. The Interstate Medical Licensure Compact. 2020. Interstate Medical Licensure Compact. A faster pathway to medical licensure. https://imlcc.org/ 

15. Foley & Lardner LLP. 2020. The National Law Review. COVID-19: States Waive In-State Licensing Requirements for Health Care Providers. https://www.natlawreview.com/article/covid-19-states-waive-state-licensing-requirements-health-care-providers

16. U.S. Centers for Medicare & Medicaid Services. 2020. Medicare coverage and payment of virtual services. Medicare TeleMedicine Health Care Provider Fact Sheet. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

17. Moore, K. 2020. American Academy of Family Physicians. Coronavirus (COVID-19): new telehealth rules and procedure codes for testing. https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/coronavirus_testing_telehealth.html

18. U.S. Centers for Medicare & Medicaid Services. 2020. Medicare & Coronavirus. https://www.medicare.gov/medicare-coronavirus

19. www.Coronavirus.gov 

20. www.medicare.gov/medicare-coronavirus#500