Issue: June 2020
Source/Disclosures
Source: Healio Interviews
Disclosures: Fleseriu, Kapadia, Klonoff, Nadolsky, Pessah-Pollack and Weber report no relevant financial disclosures.
June 19, 2020
10 min read
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Telehealth shift during COVID-19 pandemic shows capacity to deliver safe, convenient care

Issue: June 2020
Source/Disclosures
Source: Healio Interviews
Disclosures: Fleseriu, Kapadia, Klonoff, Nadolsky, Pessah-Pollack and Weber report no relevant financial disclosures.
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As clinicians around the country rapidly transition from in-person to telehealth visits during the COVID-19 pandemic, many changes must be managed at once. Endocrinologists in particular are working to find new ways to support people with diabetes who rely on data-driven care and multiple in-person visits each year, as well as patients with other chronic endocrine conditions that require close follow-up, such as osteoporosis, pituitary tumors or adrenal disease.

The shift to virtual visits has left many wondering what may come next, now that certain telehealth regulations have been temporarily loosened and a return to “normal” could be many months away or longer.

telehealth
Source: Adobe Stock

“There has been a perception that, if you conduct telehealth visits, all you need is your telephone or your laptop,” Chirag R. Kapadia, MD, division chief of endocrinology at Phoenix Children’s Hospital, told Endocrine Today. “In reality, there is a whole infrastructure behind it. In endocrinology, you need advice from certified diabetes care and education specialists, you need access to dietitians, a medical assistant who can check in with the patients and make sure the visit goes properly. You need a scheduler who can get the next appointment set up. All of those things still need to be in place, otherwise, it is just a phone call. Then there are the coders and the documentation of billing. The biggest challenge is not that we have to talk with the patient. The hardest part is coordinating the logistics around the entire practice. You have to reorient things so everyone can support you in this new way.”

Endocrinologists and diabetologists are in a unique position to provide consultation or direct care to patients via telehealth, using patient-provided history and data from the patient chart, laboratory tests and diabetes technology, Karl Nadolsky, DO, FACE, a spokesperson for the American Association of Clinical Endocrinologists and a clinical endocrinologist at Spectrum Health in Grand Rapids, Michigan, wrote in a letter to the editor published in The Journal of Clinical Endocrinology & Metabolism in April. “I have personally been advocating for more utilization of telemedicine since I was in residency and fellowship,” Nadolsky told Endocrine Today. “We knew we could do so much once clinics could download data from insulin pumps and continuous glucose monitors. In endocrinology especially, we can evaluate and comanage so many disease states with patients by talking, observing, and obtaining and then reviewing bloodwork. We can do so much good without forcing people to come in just to get paid.”

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Successful telehealth requires more than a laptop, according to Chirag R. Kapadia, MD. The entire practice staff and procedures must be reoriented.

Photo by Teresa Sanders. Printed with permission.

Still, a shift to mostly virtual visits going forward is unlikely to be seamless. Recent changes at the federal level — adopted to allow maximum patient access to telehealth during a public health emergency — could also compromise patient safety and privacy, according to experts. Additionally, any broad adoption of telehealth post-pandemic will not be possible unless temporary changes in reimbursement become permanent.

Providers, meanwhile, are doing their best to navigate such issues, all while delivering care via a device.

“We were all thrown into this pretty quickly, and we were able to make it work in a rudimentary fashion,” Kapadia said. “We are getting our patients and ourselves through this crisis intact. We are not claiming to deliver the highest and best quality care at this point. We are getting everyone through. As long as we do that, we will consider that mission accomplished.”

‘A new norm’

Increasing opportunities for telehealth has long been a goal of many providers, who have pushed the advantages of doing away with a commute to a clinician’s office and time spent sitting in a waiting room. Until recently, however, the shift to virtual visits had been a slow one. In 2019, only 8% of U.S. residents used telemedicine for care, according to a study published in the Journal of the American Informatics Association.

During the COVID-19 pandemic, that percentage has grown exponentially. In the same study, researchers observed that between March 2 and April 14, virtual urgent care visits at NYU Langone Health grew by 683% and nonurgent virtual care visits grew by 4,345%, in daily averages. During the 6-week study period, 144,940 video visits were conducted involving 115,789 unique patients and 2,656 unique providers. Of all virtual visits, 56.2% of urgent care and 17.6% of nonurgent visits were COVID-19-related.

Sandra L. Weber

To enable the rapid increase, a pool of 40 emergency medicine providers, managing fewer than 100 visits on a typical day, grew to 289 “surge” providers from multiple specialties, according to the researchers.

“In all, results reflect what may become a new norm of future health care, and in particular during periods of contagious disease outbreaks,” the researchers wrote. “With a mass mobilization of health care providers onto diverse telemedicine platforms, an aspiration of the industry for years has materialized in a matter of days.”

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Similar shifts are taking place among endocrine practices across the country, according to Sandra L. Weber, MD, FACP, FACE, immediate past president of AACE and chief of the division of endocrinology and chair of continuing medical education at Prisma Health System.

“We went from 100% in-person visits to 97% telemedicine visits in a matter of 2 weeks,” Weber told Endocrine Today. “We pivoted very quickly, but endocrinology lends itself very well to a virtual environment. There was such a willingness and adaptability, with everyone coming at this with safety in mind and thinking through how to do the best we possibly can to maintain good patient care. The transition went very smoothly.”

For some providers, the shift meant navigating virtual care for the first time, according to Rachel Pessah-Pollack, MD, Endocrine Today Editorial Board Member and clinical associate professor of medicine at NYU Langone Health.

“I did not practice telemedicine prior to COVID-19,” Pessah-Pollack told Endocrine Today. “During this time, I still needed to see my patients, but I also needed to protect their exposure as well as my own and my staff’s exposure. What telemedicine allowed me to do is continue to care for my patients without putting them at an increased risk for exposure. I have a practice where people often travel an hour or more to get to an appointment. In many ways, this is allowing them safety, but also more convenience.”

New opportunities, challenges

In an article highlighting management of type 1 diabetes with telehealth, published in April in Diabetes Technology & Therapeutics, Satish K. Garg, MD, professor of medicine and pediatrics at the Barbara Davis Center for Diabetes at the University of Colorado Denver, and colleagues wrote that the shift to remote visits could allow broader improvements in diabetes care in the long term. However, access to technology and the ability to download data from diabetes devices will continue to be hurdles after the pandemic.

“Of course, there are limitations to telemedicine, the most obvious being the inability to perform a proper physical exam,” Garg and colleagues wrote. “Some of this can be addressed, such as home blood pressure measurements and the use of video to look at the skin, [insulin] pump sites, and the feet. Still, it isn’t possible to perform a formal exam assessing for mild polyneuropathy and, for older patients, an appropriate cardiovascular exam. Obtaining accurate weight measurements can also be a challenge.”

Other endocrine conditions bring unique diagnostic dilemmas that cannot always be managed with remote visits.

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Maria Fleseriu

“My practice is pituitary and adrenal disease, so we could not move everything to telemedicine,” Maria Fleseriu, MD, FACE, professor of neurological surgery and professor of medicine in the division of endocrinology, diabetes and clinical nutrition in the School of Medicine at Oregon Health & Science University and director of the OHSU Northwest Pituitary Center, told Endocrine Today. “We have patients with urgent needs, losing vision because of large pituitary tumors, for example. These are the patients we still must see in clinic. We try to take all of the necessary precautions, of course, to decrease risk for infection for patients and health care workers.”

In an article published in May in the European Journal of Endocrinology, Fleseriu, also an Endocrine Today Editorial Board Member, and colleagues wrote that routine care of patients with pituitary adenomas can be offered via telephone or video clinics; face-to-face visits could be postponed in most cases for 3 to 6 months without compromising optimal care. Further triage of patients who might need closer follow-up or laboratory workup can also be done via telemedicine, the researchers wrote.

Despite limitations that come with no physical contact, a virtual visit can also offer opportunities for patient education, Pessah-Pollack said.

“I have evolved how I have my patients participate in the physical exam with me,” Pessah-Pollack said. “For example, many of my patients don’t even know where their thyroid is. I show them where it is, how to feel to see if it is enlarged, have them swallow. This makes the visit an educational opportunity, too.”

Nadolsky said virtual visits may also increase points of contact with other members of a care team, such a dietitians or psychologists, whom many patients may not typically see, despite recommendations.

“We have our dietitians and diabetes care and education specialists utilizing telemedicine for medical nutrition therapy and diabetes education,” Nadolsky said. “We also have an obesity/diabetes specialist psychologist who has been utilizing virtual visits to talk with patients. This is going to improve adherence and compliance to programs. I want people to talk to our dietitians and our psychologists as frequently as possible. All the guidelines say to do that, but no one wants to come into the doctor’s office every time they turn around.”

HIPAA, privacy concerns

As providers adjust practices to move to telehealth, they also must work with patients across different ages and socioeconomic backgrounds to find the best communication platforms for a successful virtual visit — and that can raise privacy concerns.

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The federal Office for Civil Rights at HHS, which is responsible for enforcing certain regulations issued under HIPAA, acknowledged that some technologies used to communicate with patients during the COVID-19 public health emergency, and the manner in which they are used by HIPAA-covered health care providers, may not fully comply with the requirements of HIPAA rules. Because many providers were forced to make a telehealth shift quickly, payors approved reimbursement for appointments conducted through a variety of technologies, such as FaceTime, Facebook Messenger video chat, Google Duo, Zoom and Skype, as well as telehealth platforms.

In March, the federal agency announced that it will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA rules against covered health care providers in connection with the “good faith provision of telehealth” during the COVID-19 nationwide public health emergency.

“When the COVID-19 emergency is declared to be over, I expect that there will be tremendous pressure on the Office for Civil Rights to continue to facilitate use of telehealth platforms to allow better access to health care,” David C. Klonoff, MD, FACP, FRCPE, medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California, and clinical professor of medicine at the University of California, San Francisco, told Endocrine Today. “Greater use of telehealth is part of a gradual evolution of medicine away from an emphasis on the history and physical examination toward, instead, data management of laboratory, imaging and sensor-generated information. I expect that after the pandemic, many patient information privacy laws, such as HIPAA, which were written before the internet revolution, will be rewritten to streamline telehealth.”

Weber said the best platform for a successful telehealth visit is one that can be easily used by both patient and provider, as long as the patient is briefed on any security concerns.

David C. Klonoff

“Having a platform that protects health information is important,” Weber said. “At the same time, if a patient chooses a platform that is not HIPAA-compliant, they need to be aware of that. FaceTime is not a protected environment for health information. ... I bring that up with anyone not using a protected platform. ... We try to use our electronic medical system platform as our first priority, because it is HIPAA-compliant ... but if someone prefers a different means, that is acceptable, so long as everyone is aware of it.”

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A ‘silver lining’

As clinicians and other providers adapt to telehealth, one big question remains: Once the public health emergency is deemed over, will things return to the way they were?

In a commentary published in May in JAMA, Carmel Shachar, JD, MPH, executive director of the Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard Law School, and colleagues wrote that to maintain the momentum for telehealth, the U.S. cannot revert to prepandemic regulations. However, recent changes “lack nuance to support clinicians while ensuring safety and privacy for patients.”

Instead, a “third regulatory path” is needed for telehealth going forward, according to the authors. That path must consider patient safety, ease of use, physician incentives to maintain telehealth practices and a more sophisticated approach to payment.

“To ensure that the increased utilization of telehealth observed during the COVID-19 pandemic is not squandered, lessons from this period of deregulation need to be thoughtfully extracted,” Shachar and colleagues wrote. “Some modifications, such as waiving parts of HIPAA, are clearly intended for a crisis but can suggest areas in which sustained regulatory change could be beneficial. Other modifications, such as payment equity rather than parity, should be considered but raise further questions about implementation.”

Rachel Pessah-Pollack

Nadolsky said payors must “step up to the plate” to provide adequate reimbursement for telehealth.

“I truly hope that the silver lining in medicine with the COVID-19 crisis is that we finally progress and appropriately utilize the technology we have available to provide more and better care for patients while also saving their time and money,” Nadolsky said. “If done correctly, telemedicine will provide better outcomes and increased patient satisfaction. I am always going to make sure patients know virtual visits are an option. It’s not going to happen magically. However, if we advocate for this and push for this — saying, ‘Look, we did it, it’s not perfect, but let’s keep working on it — I hope we’re going to make a great transition.’”

Kapadia predicted that many of the CMS waivers and reimbursement for other technologies could be phased out after the crisis passes, at least initially.

“I think we will go to a 50/50 mix of virtual and in-person visits, for diabetes care in particular, but I don’t think this 50/50 switch will happen immediately,” Kapadia said. “Most likely, there will be a snap back to the old regulations and in-person visits pretty quickly, and we will have to negotiate all of those changes.”

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