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