K. Abramson MD - UCSF CME

Tele‐Medicine During Pandemic and BeyondAnna 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‐healthBenefits and challengesPatient trendsChecklistsCosts, 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?

IntroductionPrior to 2017Hospital medicineHome/facility visits

San Francisco VA started rural telemedicine program in 2017

Goal: Meet major provider

shortages

Challenge: Major infrastructure Training for staff on new equipment

New protocols Resistance from patients and staff

Opportunity: Revitalized clinics Health equity to rural veteran communities

450kl

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

https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Center for Medicare and Medicaid Services Waiver Section 1135

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‐healthBenefits and challengesPatient trendsChecklistsCosts, platforms

Tele‐Health OpportunitiesVideo 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

http://image.slideserve.com/165062/slide38‐l.jpg

Tele‐Health OpportunitiesPatient 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 Technology Tech savvy Physical exam Limited diagnostic therapeutic procedures

Efficiency Cost Licensure

For Patients Technology Tech savvy Physical exam Trust and relationship



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

23

Medicine Specialty Modality Breakdown


24

Surgical Specialty Modality Breakdown


25

Mental Health Modality Breakdown




“Webside” Manner Office private and uncluttered Optimized lighting bright but not originating behind providerMinimal 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

• Inspection: differences on side by side comparisons• Palpation: self‐palpation to elicit tenderness and location• Range of motion: active if solo, passive with an assistant• Strength: ask patient to open fingers wide and close the fist

tight, tap fingers rapidly symmetrically, march in place with high knees, squats, walk on toes and heels, pronator drift

• Sensation: have patient self‐examine and report• Virtual physical exam validation studies indicate high utility

and correlation with in person exams

Virtual Physical Exam Techniques



What You Will Need to TelePractice:

• Computer with a webcam and microphone

• Very high speed internet connection • Telephone with Doximity dialer or similar • Second computer monitor is a major bonus• Quiet professional space with good lighting• Clinic visit note titles for video visits and telephone visits

with correct billing codes• Note templates for video and phone visits• A high dose of patience

https://www.globalmed.com/wp‐content/uploads/2018/03/why‐use‐telemedicine.png

Phone “Bells and Whistles”

• Doximity Dialer (provider side) – downloadable app• Allows you to call patients from your phone while displaying your

office or hospital number on the caller ID• Doximity also has a new video option and a one-way texting in beta

testing

• HR monitor (patient side) – downloadable apps Android/Apple• Place finger over camera to get HR with waveform

• Mental health and disease symptom trackers (patient side)

• Wearable monitor companions (patient side) – apps and hardware• BP, sleep, activity, nutrition, blood glucose monitor, ECG/rhythm

Telemedicine to a Clinic

• WallDoc screen to see life‐sized provider• Virtual stethoscope • Oto and ophthalmoscope• Derm camera• Remote ultrasound (ECHO, muscle/joint)• Digital spirometry• Remote vitals and hemodynamic monitoring systems

Telemedicine Software

• Cost per provider• Integration with current EMR• Security• Workflow for scheduler, provider, and patient• Quality of support• Bandwidth and technology requirements

Telemedicine as a Lifestyle

Picture References• Elderly home:

http://mediad.publicbroadcasting.net/p/kwgs/files/styles/x_large/public/201711/nursing‐home‐photo.jpg

• Man in trailer: https://tinyhousedesign.com/wp‐content/uploads/2009/08/A‐Real‐Bike‐Trailer‐House‐burningman.JPG

• VA map: http://image.slideserve.com/165062/slide38‐l.jpg• Man hauling a trailer: https://inhabitat.com/files/camper‐bike‐6.jpg• Woman with kids: https://www.icebike.org/wp‐content/uploads/2015/11/mundo‐01.jpg

• Walldoc demonstration: https://mms.businesswire.com/media/20170804005423/en/605169/5/Clinical_Access_Station.jpg

• Comic: https://onceuponatimewithbipolar.files.wordpress.com/2015/06/wpid‐screenshot_2015‐06‐29‐13‐43‐11‐1.png

K. Abramson MD - UCSF CME

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