Telehealth in Uncertain Times


LVM Systems

By Traci Haynes

The COVID-19 pandemic has placed telehealth at the forefront in providing healthcare services. It has forced changes in the environments in which clinicians typically practice. Individuals who, under non-COVID-19 conditions, would seek access in an emergency department (ED), urgent care, or healthcare providers’ office are now avoiding these settings. And with community spread, the Centers for Disease Control and Prevention (CDC) recommends alternatives to face-to-face triage and visits in an office setting if screening can take place via telehealth (that is over the phone, through patient portals, or online self-assessment tools). A recent report from Frost and Sullivan suggests that telehealth will increase by over 64 percent nationwide this year and continue to increase in the years ahead.

The Agency for Healthcare Research and Quality (AHRQ) defines telehealth as “the use of telecommunications technologies to deliver health-related services and information that support patient care, administrative activities, and health education.” It typically consists of a two-way, real-time interaction over distance between a patient and a clinician using audio or visual technology. 

Telehealth or Telemedicine?

Telehealth can help communicate with and coordinate care for individuals with chronic condition. Click To Tweet

Many consider the terms telehealth and telemedicine synonymous and interchangeable. However, telemedicine can describe a more limited set of remote clinical services such as diagnosis and monitoring.

In recent years, telehealth has become more recognized, especially in the aftermath of natural disasters (such as hurricanes, tornados, earthquakes, floods, and blizzards), when seeking routine care can be dangerous for both clinicians and patients. There was a tremendous uptick in telehealth interactions following Hurricanes Irma, Maria, and Harvey in 2017. Crises tend to increase the urgency of telehealth needs. 

Using telehealth in rural communities to bridge the healthcare gap delivering routine care or providing access to specialists that typically exist in more urban areas is well known. Telehealth also makes services more readily available or convenient for individuals with limited mobility, time restrictions, or transportation issues. Furthermore, telehealth can help communicate with and coordinate care for individuals with chronic conditions in supporting self-management as well as assist with earlier interventions in the face of impending exacerbations. 

Social Distancing

The critical need for the recent social distancing between providers and patients has driven increased demand for telehealth. In response to the pandemic, the Trump administration has expanded access, albeit temporary, with changes to telehealth reimbursement policies. 

Beginning March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) allowed more than 80 additional services through telehealth. Clinicians can bill immediately for dates of service on or after March 6, 2020. According to CMS, it will now pay for telehealth services under the Physician Fee Schedule at the same amount as in-person services. 

Healthcare providers, including physicians, nurse practitioners, clinical psychologists, and licensed clinical social workers, are now able to offer telehealth to Medicare beneficiaries, including standard office visits, mental health counseling, and preventive health screenings. Medicare often is the early adopter for changes in reimbursement, with other health plans following their lead. 

A May 9, 2020 report in Modern Healthcare, said that Providence went from 700 video visits a month to 70,000 a week. New figures from Blue Cross Blue Shield of MA reported that daily claims for telehealth grew from approximately 200 to more than 38,000 in May. A May 26, 2020 article in FierceHealthcare reported experts predicting 1 billion telehealth visits by 2021, and currently almost half of practicing physicians are now using telehealth appointments. 

With this shift in practice, healthcare providers will increase their use of telemonitoring devices to measure blood pressure, pulse oximetry, heart rate, temperature, and weight readings. Telemonitoring also will assess EKG tracings and views of the retina and tympanic membrane, as well as other data to diagnose patients.

Emergency Department

There is growing concern about the decreased number of ED visits for emergent situations such as acute myocardial infarctions, cerebrovascular accidents, and other life-threatening situations. Recent statistics, as reflected in emergency medical system calls, offer evidence of increased deaths at home. EDs also report that patients are waiting too long to seek care, and as a result, have often suffered irreversible damage. 

An article in HealthDay News on May 20, 2020 reported that U.S. EDs are seeing about half as many heart attack patients as usual. The data from Kaiser Permanente Northern California included 4.4 million patients. In looking at records from January 1 through April 14, they found that the weekly rate of hospitalizations for heart attacks decreased 48 percent. Moreover, fewer individuals with pre-existing cardiac conditions went to the ED from March 4 through April 14, when compared to pre-COVID-19 timeframes from the year before.

Telehealth Nursing Practice 

Telehealth, in support of the Institute for Healthcare Improvement’s (IHI) triple aim has shown improved access, quality, and cost-efficiency of healthcare delivery and has resulted in an increased demand for telehealth nursing practice (TNP). 

A medical call center with TNP registered nurses (RNs) using decision-support tools provide recommendations for care at home or accessing a higher level of care based on the caller’s symptoms. RNs do not give a diagnosis, nor do they prescribe medications, although in certain situations, RNs can provide refills or e-prescribe medications based on physicians’ orders. 

The breadth and scope of TNP have advanced throughout the years. It has had a major presence in the United States since the 1960s, in Canada since the 1970s, and the UK beginning in the 1990s. 

In the last half of the 70s, health maintenance organizations (HMOs) began using telephone triage and advice services as a gatekeeper to control consumer access to care. In the 80s, hospital marketing departments used telephone triage as well as physician and service referrals, class registration, and health education and information services to attract and keep their market share. Once again, in the early to mid-90s, managed care organizations further expanded telehealth services for demand management, recertification, and referral authorization due to the ever-increasing incidence of chronic illness and multi-morbidities as well as the associated rise in healthcare costs. 

Present-day, the COVID-19 pandemic, has led to the role of telehealth nurses providing triage, surveillance, and monitoring for disease management, care management, case management, care coordination, and clinical prevention programs.

Conclusion

The use of telehealth has grown exponentially during this pandemic. It has filled a much-needed void in providing qualified medical care by clinicians without the necessity of commuting to a higher level of care. It has proven positive outcomes and high degrees of satisfaction. Telehealth is convenient and accessible, and while an option for many medical situations, it is especially important to know of its reliability during a public health emergency.

Traci Haynes, MSN, RN, BA, CEN, CCCTM is director, clinical services at LVM Systems.