By Saad A. Mir, MD
Assistant Professor, Clinical Neurology, Weill Cornell Medicine; Assistant Attending Neurologist, New York-Presbyterian Hospital
Dr. Mir reports no financial relationships relevant to this field of study.
SYNOPSIS: Telemedicine has rapidly transformed healthcare delivery during the COVID-19 pandemic, but innovative reimbursement models and updated privacy regulations are needed to ensure widespread implementation of high-quality digital care.
SOURCES: Keesara S, Jonas A, Schulman K. Covid-19 and health care’s digital revolution. N Engl J Med 2020; April 2. doi: 10.1056/NEJMp2005835. [Online ahead of print].
Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med 2020;382:1679-1681.
COVID-19 has changed healthcare dramatically. Hospitals have converted emergency rooms, operating rooms, and stepdown units into ventilator-capable intensive care beds. Nurses, respiratory therapists, medical students, and physicians have been redeployed within hospital systems to accommodate the surge in ventilated patients. Overwhelmed hospitals graciously have welcomed volunteer care providers who have been granted state-mandated emergency privileges. Aside from brick-and-mortar transformations, hospitals and care providers also have leveraged telemedicine as a vital tool to increase access to care, maintain social distancing among patients and providers, and allow non-COVID patients to maintain essential outpatient management.
In their perspective piece, Keesara et al discuss how telemedicine can reduce the inflexibility of an analog healthcare system during pandemics. However, for telemedicine expansion to be successful, a unified strategy that addresses reimbursement, regulatory relief, and quality of care evaluation must be created. Scarce telemedicine payment structures and the limiting of Medicare reimbursement to rural areas historically have led to poor adoption.
As a response to the pandemic, Congress allowed telemedicine reimbursement for all Medicare patients regardless of geography. However, further reimbursement models need to be created to address novel methods of telemedicine, technical fees to support infrastructure, and innovative care models, such as “hospital-at-home care.” With consistent and broad reimbursement structures, regulatory relief would be needed, since 94% of hospital systems cite privacy concerns and penalties as limiting factors in telemedicine implementation.
During the pandemic, the Department of Health and Human Services (HHS) has agreed to waive any penalties for using non-Health Insurance Portability and Accountability Act compliant means of telemedicine. New definitions of security need to be created, since technology advances far faster than the laws created decades ago. One solution would be for HHS to allow the use of commercially available encrypted telemedicine services. Ultimately, studies will be needed to quantify how telemedicine strategies affect quality and cost of care.
In a similar perspective, Hollander and Carr describe a variety of telemedicine initiatives that are being implemented across the United States. These interventions are being used in prehospital, inpatient, and outpatient settings. Patients at home can have paramedic visits with telemedicine physician evaluations to prevent unnecessary visits to hospitals, as has been done successfully by Houston’s ETHAN project.
Another model being used at more than 50 hospital systems is a “forward triage” model in which patients at home can be evaluated, treated, and monitored for COVID-19 symptoms and recovery. Similarly, chat bots are being used to triage patients to testing facilities or escalate them to a care provider. If testing limitations could be addressed, widespread implementation of telemedicine chat bots, forward triage, or paramedic evaluations could reduce the burden on hospital systems significantly. Within hospitals, emergency room telemedicine triage allows providers to cover many areas while maintaining their safety. Disinfected tablets can be given to patients to allow communication with care teams or with family members. For outpatients, many centers have converted routine clinic visits to be done solely via telemedicine. All of these interventions allow providers to expand their availability to multiple care settings, as well as to continue to provide care if they happen to be quarantined.
Telemedicine is well positioned to alleviate the challenges associated with the current COVID-19 pandemic, while also disrupting traditional paradigms of healthcare moving forward. Many hospitals have expanded existing telemedicine capabilities. At our own institution, New York-Presbyterian Hospital, we have implemented forward triage, increased inpatient telemedicine consults, launched tablet-based communication with inpatients, moved primarily to outpatient telemedicine visits, increased remote patient monitoring to track patients’ vitals at home, and are establishing electronic intensive care unit monitoring. For these models to maintain quality care beyond the pandemic, reimbursement structures and government regulation need sweeping modernization to meet the rapid innovations in healthcare.