Telemedicine Visits: Are They Right For You During and Beyond COVID-19?

The skeptical cardiologist, like most physicians in America, began converting scheduled in-person office visits to “telemedicine” visits in late March when it became clear that  COVID-19 was spreading rapidly.

It made no sense at that time to bring patients into our office for regular visits who were vulnerable and high risk, exposing them to physicians and staff who might have asymptomatic COVID-19 and vice versa.

Telemedicine made a lot of sense. As eloquently expressed by Dr. Russel Libby:

With the evolving COVID-19 pandemic and its impact on access to medical care, there is no better time to help physicians navigate and implement telemedicine into their practices and enhance their ability to care for patients. Through telemedicine, we can triage patients and help avoid unnecessary visits to health care settings, thereby reducing exposure to the COVID-19 virus and helping to keep our front lines safe, ensuring they have the resources needed to take on this immense challenge. The tools and guidelines being created now are already helping many to use telemedicine and will continue to help define its role at this moment, and shape the future of physician practice.” 

I wrote a post on March 20 (but didn’t publish it for some reason) explaining this change to patients:

Because the virus can be spread from infected individuals before they have symptoms there is a risk that patients can be infected anytime they are out in public.
Infected patients can visit the doctor’s office without any symptoms and transmit the virus to health care workers and other patients.
The perfectly healthy person sitting near you  in the doctor’s waiting room could be infected.This means you should reserve  seeing in person a doctor for when it is absolutely necessary that you be examined.

Due to the above concerns, beginning yesterday I personally began contacting all patients on my office schedule for the day.  After having a conversation with them, if  they were doing well and could delay their visit, the appointment was canceled. I encourage all physicians and patients to do everything they can to minimize unnecessary health care visits. Stop elective surgeries and screening procedures. Stop routine check-up visits.


The Rise of Telemedicine

Fortunately, due to COVID-19 CMS changed its coverage policies for telemedicine and has been reimbursing visits done utilizing video connections as if these were office visits.

For those individuals who do not have the ability to connect via video means (including Face time, WebEx, Zoom,and  Doximity) we have been utilizing telephone only visits. CMS has also ramped up reimbursement for these interactions.

In addition, I can see new patients as a telemedicine visit since CMS announced waivers on old restrictions.

CMS also announced that “the requirement for physicians to hold a license in the state in which services are rendered is waived.”

Rules, coding, and reimbursement for billing are in flux right now but I have found CodingIntel.com to be a reliable source and this summary PDF from Woodcock and Associates to be unusually clear:

I’ve been trying to get my employers to utilize telehealth services for several years unsuccessfully. I think they make good sense for many patient situations, especially when combined with the kinds of remote patient monitoring (like Kardia Pro) have implemented with my patients.

Hopefully, now that telehealth has been expanded it will become the norm after COVID-19.

 


Telemedicine Visits Work For Many Patients

It’s been two months since we began utilizing telemedicine visits and we have successfully flattened the curve of the epidemic.

For the most part, I think the telemedicine visits have been successful in allowing me to check on the status of my patients and manage their cardiac conditions. We are typically able to get the patient to record a home blood pressure and heart rate. Many of my patients have home ECG devices (mostly Kardia) which allow us to monitor their cardiac rhythm

The video allows a rudimentary physical exam. I can tell how the patient is breathing, speaking, and answering questions. I can see any gross abnormalities of their head, neck, ears, and eyes.

One significant limitation is that  I cannot listen to their heart and lungs. In cases where patients are having difficulties that would best be assessed by a full physical exam or by an ECG  we have brought them into the office.


Reopening

On May 18 St. Louis City and County officials announced the reopening of certain businesses. Of note, hospitals and doctor’s offices weren’t mentioned in these announcements.

The CMS document on “Opening Up America Again” states:

Therefore, if states or regions have passed the Gating Criteria (symptoms, cases, and hospitals) announced on April 16, 2020, then they may proceed to Phase I. The Guidelines for Opening Up America Again can be found at the following link: https://www.whitehouse.gov/openingamerica/#criteria

Maximum use of all telehealth modalities is strongly encouraged.

In conversations with patients these last 2 months I have found that they have almost without exception been sheltering at home and practicing social distancing and have been very happy to conduct the visits using telemedicine.

Of course, some have elected to reschedule follow-up visits to a future time with the hope that COVID-19 will be less of an issue and these are the patients I’m not having conversations with.

In the next few weeks I will be personally contacting patients on my schedule and assessing their need and desire for an in-person office visit.

The guidance I have from CMS and from the leadership of my medical group is to continue primarily favoring telemedicine visits. However, if my patient has a strong preference for an in-person office visit or if I perceive that a physical examination, vital sign check, or ECG is essential for their proper care we will keep the in-person office visit.

I’d appreciate hearing all reader’s and patient’s thoughts on this topic so feel free to leave comments or email me at DRP@theskepticalcardiologist.com

Virtually Yours,

-ACP

Feature Image

LDN 1471: A Windblown Star Cavity
Image Credit: Hubble, NASA, ESA; Processing & License: Judy Schmidt

25 thoughts on “Telemedicine Visits: Are They Right For You During and Beyond COVID-19?”

  1. Hi Anthony. I can really endorse the value of telemedicine visits. Have had them with my cardiologist and my nephrologist. In both cases all issues were discussed and satisfaction achieved,
    Dad

  2. I found the telemedicen “visit” to be fine for my situation.

    A couple of issues did arise. First there appears to be no place I could fine that described the process for using Webex, or Zoom for the “visit”. The personnel in your office do not really have the expertiseor time to go into explaining this to patients. My visit was conducted via iPhone FaceTime which was adequate, however I would have preferred the larger screen on my computer.

    Also, according to the office personnel the only way to get my three month blood pressure readings to you was to fax them. The “myStlukes” portal does not have the option to attach a file to a message. If there is another way to send files there should be an explanation of that process.

    Bob F.

    1. Bob,
      Thanks for the feedback. The logistics and mechanics of our telemedicine process is a work in progress. We end up using multiple modalities including Facetime (for iPhone users), Webex for those who can master it on a computer, and Doximity. Doximity theoretically should be the simplest and most widely applicable but we have frequent issues with it. With Doximity app video dialer I enter in the patients cell # and they are sent a text. If they click on the text it should take them to the “virtual room” where I am waiting. Sometimes after multiple episodes of waiting i end up calling the patient on their phone and we have a telephon only visit.
      I’ve heard the same issues from other offices and different practices. My daughter, Chelsea Pearson, MD is using Zoom.
      With respect to BP readings I agree that there is no good system with our EMR. Why can’t patients attach a file and upload it??????
      Many of my patients still mail in there two week readings. Some enter them in one by one into the patient portal. Some email them to us.
      The best method is to utilize an Omron bluetooh enabled BP cuff, upload to the cloud and connect by kardiaPro.
      Dr P

      1. I believe the prohibition on attaching files to messages to hospitals and medical facilities is due to the risk of malware.

  3. My dentist has a practice of wait in your car, not the waiting room, and then be called in and go directly to dental work station/room. Any chance of doing something like that for required lab tests for a televisit with Doctor. Lab work waiting rooms have more people in the waiting room and a great variety of ailments and conditions.

    (clearly my dentist has a parking lot. might not be possible in large cities,)

  4. I think telemedicine visits are here to stay.

    My wife had a telemedicine visit with her SLH-affiliated doctor for a new problem about six months ago. She had a persistent conjunctivitis and wanted some help managing it.

    It was about a 10 minute appointment that she took from the desk of her home office. One year ago, that 10 minute consultation would have taken about two hours: walking from her corporate office to the car (10 mins), driving to SLH from downtown (25 mins), walking from SLH parking lot to office (10 mins), wait time (10 mins), etc. You get the idea.

    Unless an in person physical exam or additional testing is required, the telemedicine consult is her preferred appointment going forward.

    She has also since had a Derm visit, and I would not be surprised if not visiting in person saved her from an unnecessary biopsy. 😉

    1. I hope you are right. The time-saving aspects are really helpful for busy/working patients like your wife. And for patients who find the logistics of leaving home and getting into an office they can be very beneficial.

      I’m intrigued by your observation on the “unnecessary biopsy”….. tell us more.

      I think you are touching on an important point. Many tests and procedures are done on patients because they are present in the office. In the world of cardiology, many practices routinely do an ECG on every patient. There is nothing to suggest this is warranted for the majority of routine follow up visits. In fact, it has the potential for creating unnecessary anxiety and down-stream testing.

  5. I’ve been using the KardiaMobile personal EKG to monitor my heart for afib. Like the blood pressure cuff you mentioned, the monitor uses Omron to create the output. The results can be saved as PDF and then sent to my physician. Both my PCP and my cardiac doctor love this device. Available at Amazon for $149 (https://amzn.to/3d2OGxA)

  6. Kaiser Permanente has used telemedicine, phone and email for years. I can attach photos or documents to emails in pdf or jpeg format. This has saved me numerous office visits with no discernible issues. It is very cost effective for both Kaiser and me. I have no trouble at all getting an office visit if I request one. Obviously, I can’t simply phone my physicians; I can make a phone appointment. Of course, they can call me, and have, at any time.

    When I lived in Florida (no Kaiser), my personal physician refused to communicate with me in any way except via office appointments because she was reimbursed only for those – one reason medical insurance costs so much in this country.

    1. Seems like Kasier Permanente is on top of telemedicine. And your experience suggests that IT departments can solve the issue of malware coming from emails with PDFS or JPEGS.
      Your experience with ease of getting a visit is mirrored by my experience of being able to offer same day telemedicine visits for most patients calling with acute problems.

      Your Florida doctor experience reflects the fact that the reimbursement model for physicians did not compensate for anytime spent outside the office visit or billable procedures.
      A large percentage of my days are spent dealing with requests, questions, clearance, reviewing labs and imaging tests and BP recordins, medication problems and a host of patient-related issues. Although crucial to patient management this time was not reimbursed. I am available 24/7 (except on some weekends or vacation) for emergency or urgency calls from my patients but CMS/insurance reimburses me nothing for that service.

    1. The Kardia ECG will have variable performance with a pacemaker. If the rhythm contains ventricular pacing the algorithm will likely call it unclassified.
      However, most patients with pacemaker devices have remote monitoring capability.

  7. Interesting blog, especially since
    I found a recent telemedicine call for a routine visit with my primary To be nearly useless, at least to me. Do you think that increased use of telemedicine will lead to marginalized skills in those methods that can only be accomplished in an in person visit?

    1. Can you tell me why the visit you had was nearly useless?

      Your question is intriguing..
      “Do you think that increased use of telemedicine will lead to marginalized skills in those methods that can only be accomplished in an in person visit?”

      What the methods/skills in question?

      The physical exam? I’m afraid that physical exam skills have been gradually declining over the last 30 years. I could write an entire post on this topic.
      This decline has only been enhanced by electronic medical records which have led to the “macro” physical exam documentation.

      Do you think that increased use of telemedicine will lead to marginalized skills in those methods that can only be accomplished in an in person visit?

      1. The visit occurred at the very beginning of the pandemic. I think both the doctor and I were inexperienced with the process and therefore uncomfortable with the change. My “visit” did not include video. It was just Q&A in teleconference. I admit that at the time I don’t think either of us were ready to embrace the technology. Another factor may have been that it was a routine visit so there were no complaints to discuss.

        I think your blog has introduced or reminded me of some constructive things that would make a telemedicine visit more productive.

        Concerning methods and skills in question, I meant things like inspection, palpation, percussion, and auscultation.

        Whether I think skills will be marginalized, I don’t know. I was deferring to your opinion as the professional.

  8. As an emergency physician, I have served patients in Kaiser’s phone system for 20 years and now in private practice telemedicine.The modern experience is quick, pleasant, reasonably helpful. Many people who call me would have gone to the emergency department because they did not know better, or they could not get the help they need a timely fashion from their physician. I handle a wide range of complaints most frequently UTI, respiratory infection, anxiety, medication refills, and the near universal desire for antibiotics. Patients are able upload images of rashes and I can make a good stab at diagnosing. Because I have spent so many years in the emergency department, I know what would happen to these patients if they came and we can just jump right to that. I also know what an emergency looks like and can quicken the move to the emergency department for those patients. I think this is a very good thing made possible by reimbursement and availability.

  9. Kaiser always seems to be at the forefront of primary care innovation- likely because within that model, care + coverage are aligned. As this post points out, the main obstacle to telemedicine for us PCPs in more traditional models has been insurance coverage. In the past, it was frustrating to see private insurers direct patients to their own virtual docs- presumably to save money- which is frustrating for continuity of care. I certainly hope the private insurers don’t take away our ability to do telemedicine when the pandemic has lulled. Certainly, for some issues, telemedicine is more than adequate (anxiety/depression medication discussions and follow-ups come to mind) and much more convenient for patients.

  10. Most physicians using the “direct primary care” model of medicine use telemedicine as one of their main ways to interact with their patients. Unlike the traditional model of medicine, this model eliminates all insurance in favor of a monthly subscription that provides 24/7 communication with your doc via email, text, phone. In my case, I pay $75/mo and receive discounts on medications, labs, and procedures that he has negotiated to set up with other providers. I went on Medicare last year and chose to remain a subscriber with my PCP because of the amazing level of care he can provide using this model of medicine. This is the way that doctors interracted with patients prior to insurance companies getting between them.

    Sorry for going off topic, but I get so frustrated when a person’s quality of medical care is dictated by an insurance company. It sounds like Kaiser is at least pointing in a much better direction to address that.

  11. I had an excellent experience with my doctor using telemedicine. I was nervous about going into the office and this way, I could chat with my doctor about my health concerns. The only downside was when he suggested I could use some makeup 😛

  12. Since lockdown started, I’ve been using telemedicine for my teen’s monthly Accutane appointments and it’s been a revelation. Before, I’d have to pull him out of school and we’d sit through 45 minutes of Bay Area traffic, each way, to have his dermatologist look at his face, advise him to moisturize and wear sunscreen, and send us on our way with a new prescription. Now, he texts her a selfie, she looks at his face, there and through the conferencing app, advises him to moisturize and wear sunscreen, and electronically submits the new prescription. 10 minutes flat. It’s beyond wonderful. I feel as more and more tests & monitoring devices become widely available for home use, a greater range of appointments will become tele-practical. I can’t wait!

    Speaking of new monitoring devices, I recently got an ad on FB for this: https://indiegogo.wearlinq.com/?fbclid=IwAR0LPLk7dNMXBay_t6uPkP93j_MrAQUpmJbsT_yyREz96fVZ2SuITrlDvsQ Would love to hear your first thoughts! 🙂

  13. The telemedicine appointments I have had have left me both comfortable and satisfied. I find I come to the appointment better prepared than usual ie I have my BP readings, my questions etc at my fingertips. However from time to time I would like a face to face appointment as I feel the human connection is important.

  14. I think in future telemedicine became very popular in all over the world and the rise of telemedicine increases very fastly, specially in this time when we fight with dangerous virus of covid – 19,.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.