• Guest Editorial

    Implementing Telemedicine on the Fly, on a Shoestring

    April 21, 2020 5:10 pm Russell Miller, M.D. — I heard about the first confirmed cases of COVID-19 in Pennsylvania while I was at our state chapter's annual conference in early March. Those casual discussions at the meeting in Hershey revolved around what this meant for our commonwealth, our practices and our patients. 

    Russell Miller, M.D.

    I am a solo, independent family physician in rural Cambria County, about 90 miles east of Pittsburgh. My practice consists of me, a physician assistant, an office manager, two medical assistants, a medical secretary and a part-time LPN. We care for about 2,500 people in a health professional shortage area, ranging in age from newborn to 102. The area has little infrastructure for the 21st century, let alone for a pandemic. Many people have poor internet service (some still use dial-up service!) and, with a mostly elderly population, comfort with technology is challenging for my patients. Even while enjoying the conference, I worried about my practice adapting to this looming threat.

    What follows are highlights of a journal I kept as I quickly adapted my practice to a telemedicine model that would allow me to care for my community in an effective way that was safe for patients, staff and me while keeping the worried well and mildly ill out of emergency rooms and urgent care centers.

    Friday, March 13

    I get up at my usual time and begin poring over CDC and state department of health webpages regarding COVID-19. There is not much other than the risks, symptoms and testing criteria. I find -- or confirm -- that there is a terrible lack of testing ability across the nation. There is absolutely nothing directing outpatient offices/clinics about our role in fighting this new virus.

    I had been planning for months to offer telemedicine visits. In fact, I ran a beta test in the fall with a friend -- one of my patients -- who had been hospitalized and had emergency surgeries. He lived some distance from my office, and we discussed using FaceTime. My patient knew there was concern that the app wasn't fully HIPAA-compliant in 2019, but he encouraged me to try a virtual visit. It went well. I was able to do a transition-of-care visit, reconcile his meds, evaluate his colostomy stoma and have a good discussion about his harrowing hospitalization and his anxiety. And his insurance paid for the visit. 

    My EHR has a telehealth module, but I knew that activating it could take weeks. Also, developing information for my patients and "campaigning" for telemedicine was not something I relished. Staff education and buy-in was a third issue. I have great staff members, but I worry that they may interpret my desire to use telemedicine not as an expansion of service but as a replacement of their work.

    During my research, I found a CMS bulletin from March 6 saying that the HIPAA regulations that pertain to FaceTime, Skype, Google Duo, etc., will be relaxed.

    There is some encouragement about using telemedicine to evaluate and monitor quarantined patients, but not much on a whole practice overhaul for wider patient care.

    By 3 p.m., I have enough information and decide that telemedicine on a large scale is the plan for my practice during this pandemic.

    Sunday, March 15

    My job in this, for now, is to keep people well and well informed. My chronically ill patients are at highest risk, especially if they are older. Telemedicine would allow me to evaluate them more effectively than a phone call and more safely than an office visit. Even using telemedicine to keep "regular appointments" for well patients and those with well-controlled chronic diseases allows me to educate the local population about the virus and champion the idea of social distancing and staying home. It also keeps us from having to just reschedule everyone -- and from having to decide how far out to reschedule. A month? Two months? Well, I have a plan and I have a conception of a mission. Let's see what tomorrow brings.

    Monday, March 16

    Here it is. The day of change. I get to the office early before the staff to start my computer and get my game face on. The staff arrives and so do the first four patients, a couple of them 45 minutes early. I cannot catch a break. I go into the waiting room and apologize, explaining that I need to have a quick staff meeting. Not surprisingly, folks are understanding.

    I unveil my plan to my staff -- how we are going to use FaceTime for telemedicine, our role in the grand medical scheme of things and so on. I assure them there is a learning curve for everybody, including me, and it is steep.

    This first day there is a lot of flux in the schedule. Calls, cancelations, rescheduling. By day's end, my PA and I have seen 31 patients, 11 via telemedicine. As promised, the learning curve is steep, nearly vertical. I go home with a roaring headache.  

    Tuesday, March 17

    Day 2 of telemedicine dawns somewhat more promising -- for the office if not the nation.

    The younger staff members have wrapped their minds around what we are trying to do. They all jump into calling the week's patients and offering them this alternative. There is an interesting phenomenon: We offer folks a telemedicine visit in lieu of the regular visit and they refuse. Oftentimes they say, "Why would I pay a copay for a video chat?" We then inform them that most insurers have waived copays during the pandemic. Patient buy-in is a challenge as they still refuse. However, later in the week, some will call back and take the telemedicine appointment. When asked why, most say something about hearing about it on the news. As one woman said, "I told my sister from State College you were doing this, and she made a smart comment about how could that be, because we are out in the boonies. I told her, 'Because he keeps up with the times." Unfortunately, I feel our health care system is behind when it comes to safely and efficiently responding to this pandemic.

    In the evening, I call a friend to wish her happy birthday. She and I went to medical school and residency together; she is now on faculty at the residency from which we graduated. She asks about my plan for the oncoming chaos and I relate my preparations. She's interested, asks astute questions and makes several good suggestions.

    Wednesday, March 18

    Things are going reasonably well. New twist: We are getting calls from hospitals for follow-up after discharge. We make appointments but then call the patient after they return home to describe the telemedicine plan. We also decide that we need to "pre-chart" with these patients before telemedicine to confirm dates of hospitalization, confirm hospital documentation and reconcile meds. This can be done on the phone and helps smooth the telemedicine visit.

    I received a text from my med school/residency classmate asking if I had time to do a conference call with the residency about my foray into telemedicine. I do. I outline the process I use and email them the CMS documents regarding telemedicine billing and covered services and the bulletin regarding the relaxing of HIPAA regulations.

    We discuss that the billing is done by using the routine E/M codes but adding the -95 modifier and 02 as place of service, indicating that it is being billed as a telemedicine visit. My friend is searching the web and finds the Doxy.me telehealth platform, which has a free option. The phone call was at 10 a.m., and by early afternoon the residency is doing telemedicine visits.

    March 19-20

    We continue to transition visits to telemedicine. Still, the majority of routine visits are rescheduled. But more patients with chronic illnesses are acquiring blood pressure cuffs, pulse oximeters and thermometers. Most have scales. So, vitals can be obtained. It is not how I want to practice, but it does allow a practice to acquire a certain nimbleness to rise to the challenges we face. We are seeing one-fourth to one-half of our usual patient load, almost 100% of them via telemedicine. Only one or two patients per day need to be physically in the office for things that are impossible to do via telemedicine, such as suture removal or ear lavage.

    After a day or two, my PA and staff are fully on board, and this helps tremendously.  Hopefully, I can do my job: Keep people healthy, triage cases to try to lessen ER visits and manage those quarantined due to COVID-19. On March 19 I had the last check-in visit with three patients who self-quarantined two weeks ago. None of them developed symptoms, and now they can go about their lives in the new normal we find ourselves navigating. Unfortunately, I know they will not be the last patients I will have to guide through quarantine. And, as much as I hope and pray otherwise, I must be realistic that some may not have such an optimistic outcome.

    Russell Miller, M.D., is a solo family physician in rural Pennsylvania.