Practicing Remotely: How Providers Have Adjusted to Using Telehealth During COVID-19

Wide use of telehealth has been historically limited by lower reimbursement rates for providers, regulatory guidelines, and security concerns. In these changed times, however, telehealth has quickly become a new norm.

AS THE COVID-19 PANDEMIC sweeps the world, a lot of media attention has been given to the patients admitted with this virus. However, across the United States, patients are still experiencing heart attacks, still need dialysis, and still rely on crucial medications to function. While some providers have had to temporarily close their doors under stay-at-home orders, other providers have been able to continue serving their community and patients with telehealth.

First adopted in the 1960s to monitor the health of astronauts from the ground, telehealth has evolved steadily over the subsequent decades. 3 Until now, wide use of telehealth was limited by lower reimbursement rates for providers, regulatory guidelines that vary state to state, and security concerns. However, with many Texans now unable or unwilling to come into the office, telehealth has quickly become a new norm.

QUICK TRANSITIONS

“It has drastically changed,” says Mia Painter, DNP, APRN, FNP-C, who has been practicing for over ten years at San Marcus Family Medicine. Her organization already had established telehealth services integrated into their electronic health records, so they were able to shift nearly the entire practice to telehealth quickly.

“Prior to COVID-19, we were doing telehealth education for diabetes management. We reduced glucose levels in our patients dramatically, and they enjoyed having access to care without having to come in.”

Staff and providers at her clinic found it easy to transition. In a day, the clinic may see between 24-30 patients per provider with extended business hours to accommodate patient schedules. “We still have one nurse practitioner at the clinic for urgent hands-on evaluations, and we are doing drive-up testing for COVID-19,” Painter says. “Everyone else is doing virtual visits from home. We are trying to keep our patients out of health care facilities to reduce the risk of exposure.”

At a rural family practice clinic in the Texas panhandle, Mary Hazel Brantley, DNP, APRN, FNP-C, says her facility has moved towards more telehealth but are still trying to accommodate patients who request an in-person appointment. “A lot of patients who need follow up are older, so it’s harder for them to install an app or use a smart phone,” she says. “Some patients, especially the younger ones, are more receptive about virtual visits and phone visits.”

At the same time, Brantley has seen some older patients who are leery of seeing providers due to social distancing and exposure in clinics. When telehealth is an option, Brantley and her team may do just a phone call or use FaceTime since HIPAA requirements are currently more lenient. “We don’t have a portal yet. We are trying to find a way to use one platform through the whole clinic.”

Both nurse practitioners say their clinics have made the transition easy for patients by letting them schedule the same way they always do. The nurse or doctor will then give them a call at the appointed time.

EASED RESTRICTIONS

In the United States, telehealth is primarily limited by state legislation. While we have used the generic term “telehealth” in this article, in Texas, “telemedicine” is performed by or delegated by a physician—to an advanced practice registered nurse for instance—and “telehealth” covers any other provider, such as registered nurses. Under normal circumstances, telemedicine requires a provider-patient relationship formed through audiovisual technology. The COVID-19 disaster declaration waived the audiovisual requirement, allowing for audio-only services. On the federal level, the Office for Civil Rights has stated that they will not be enforcing HIPAA rules, so non-HIPAA compliant platforms such as Skype and FaceTime are permitted.

Reimbursement can also complicate how nurses provide virtual health care. In Texas, an emergency rule requiring parity in state-regulated commercial plans means an insurer cannot refuse or limit reimbursement for electronic services. However, the state only regulates select insurance plans, such as marketplace plans and some employer-sponsored plans. Texas Medicaid falls under similar rules, but not all codes are reimbursable. Medicare also allows some audio-only services and has lifted restrictions on patient locations. Unfortunately, regardless of the program, providers must determine if their billing codes are reimbursable by the specific payor and allowed through the specific platform.

IRREPLACEABLE VALUE

Both Painter and Brantley concur that nothing can replace in-office visits. “You’re not able to fully assess the patient. You can’t listen to their lungs or feel their pulse,” says Brantley.

“Some medical conditions do require a hands-on examination,” Painter agrees. “The provider must be diligent about what can be seen in telehealth and when the patient needs to come to the office.”

On the other hand, telehealth makes health care accessible to people who would otherwise have to travel long distances, or even risk their health, to come to an in-office appointment. “It is allowing us to reach a larger portion of patients who would not have access otherwise,” says Painter. “I was able to see a patient who was stationed across the state without the patient having to travel for hours. I’m afraid if we go back to prior telehealth restrictions, we’ll cut off access to patients that need telehealth services.”

As workplaces conduct more virtual meetings and become more accepting of teleworking, many predict a shift in work culture that would not have happened without COVID-19. The same may be true of telehealth as well.

“At one time, if we were approached about telehealth, I wouldn’t have entertained the possibility of doing it,” Brantley says. “I work in a small rural hospital, which at one point lacked adequate funding to have equipment and software for telehealth, so I had to find creative ways to integrate telehealth into our current practice. But telehealth and virtual visits will continue to have a place in the future.”