Daniel Park, DMSc, PA, of Keck Medicine of the University of Southern California in Los Angeles, began treating patients using telemedicine in the summer of 2019. From his clinic, he was able to visit virtually with post-operative urology patients in their homes. Telemedicine allowed patients who lived long distances from Keck Medicine to avoid the hours-long drive to see him, and spared those who lived nearby of having to deal with Los Angeles’ notoriously bad traffic.
Dr Park, Director of Clinical Operations at Keck’s Institute of Urology, lauded virtual care, but most of the other urologists at the institute were not convinced. But the world has changed in the past 4 months.
“Everything shifted overnight, and we have had a 2000% increase in usage since the COVID-19 pandemic hit,” he said.
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Urologists at Keck Medicine are only seeing urgent/emergent patients in the outpatient clinics. Most other care must be handled by phone or online for the near future. Addressing this need, the Centers for Medicare and Medicaid Services relaxed payment and care limitations in March, making it easier for providers to treat patients virtually. Even as some areas plan to gradually reopen, many providers hope these emergency changes will become permanent.
“I’ve been calling it the COVID catalyst,” Park said. “Now is the time do things differently and break down administrative and insurance barriers for telemedicine. You can’t solve healthcare’s problems with the same level of thinking that was used when we created them.”
Federal changes
Prior to the recent pandemic, Medicare strictly regulated how patients could receive virtual care. CMS mainly paid for telemedicine visits for rural patients and for limited types of visits. They have now expanded the services in several ways including:
- Payment parity for virtual and in-office visits
- New and established patients can now be treated
- Doctors can treat across state lines
- Patients can receive visits from home
- Virtual check-ins have been expanded
- Frequency limitations for some visits have been removed
- Payment is available for end-stage renal disease visits
Before these changes, Park was providing much of his telehealth services without billing patients. Now, though, he is working in the clinic twice a week and telemedicine fills up the other days. Everything other than immediate post-operative care has been shifted to virtual encounters, including new, nonurgent patients and follow up visits.
“There really has been a huge paradigm shift,” Park said. “There is an entire telecare team that preps the patient, does medication reconciliation, checks for allergies and does a test run prior to the visit. It has evolved into a relatively seamless platform and is likely here to stay.”
Beyond COVID-19
Carol Peden, MD, MPH, Professor of Anesthesiology and Director of the Center for Health Systems Innovation at Keck, has worked on developing a telemedical strategy for the medical system, and the Telecare team were slowly credentialing physicians and staff when the pandemic hit. Keck went from a slowly growing program to delivering enormous amounts of virtual care in a very short period. “We have finally broken the inertia toward doing this,” Dr Peden said, adding that she hopes the burgeoning interest in telehealth will continue beyond the pandemic.
Telemedicine can greatly expand access for some specialties with a scarcity of practitioners. In urology, with an increasing number of Baby Boomer patients, an aging workforce (25% of urologists are older than 65), and areas underserved by urologists (70% of US counties have either 1 or zero urologist) could create problems across the country, Park said.
Telehealth may reduce some of the factors involved in physician burnout. Dr Peden related that doctors have told her the ability to engage in virtual encounters allows them to focus more on one-on-one interaction with patients. Telehealth also makes working at home an option, and thus potentially could improve work-life balance. It could also help doctors interact with a greater number of patients and, if necessary, involve family members and caregivers in a consultation.
Telemedicine can assist in many aspects of care, even in some less obvious areas such as respiratory assessment, Dr Peden noted. An online visit rather than a phone call could allow doctors to obverse if patients are frail or having problems in their home. Telemedicine can enable doctors to observe patients’ surrounding, which can be important when evaluating potential environmental issues.
Dr Park said telemedicine has the potential to bring various specialties and organizations together. Remote second opinions can be helpful, particularly for doctors in rural areas. He said he envisions a time when urology, medical oncology, radiation oncology, pathology and radiology are part of a single virtual visit with a patient remaining at home.
“It could further open the doors for things like remote telesurgery or teleproctoring, or mentoring and telesimulation,” Park said. “It could increase overall collaboration, a sharing of knowledge and expertise amongst multiple programs, perhaps leading to a nationwide or global training platform.”
Getting started
Though insurance and technology may have hindered uptake of telemedicine, Park said the main obstacle is often that doctors are many times too busy to learn and adopt it into their clinical practices. Now many physicians have been baptized by fire.
Dr Park has some recommendations for making the transition smooth. First, he suggests pairing up with someone who has some experience before doing it alone. Second, do not overbook appointments when learning the ropes. Once comfortable and familiar with the platform, increase the volume as needed. When he started out with telemedicine, his initial virtual visits were post-operative in nature, following nephrectomies and prostatectomies, reviewing their final pathology and incisions. Now he is seeing new and follow-up patients.
He recommended starting slowly—3 to 5 patients initially—and build the program. It also might be a good idea to have an IT team perform trial-runs with patients before the first visit, particularly older patients who may not be tech savvy. Finally, Park stressed the importance of treating any virtual encounter as a regular clinic visit. “They [physicians] are billing for this, so they have to remember the importance of detailed documentation, billing and coding given it’s a legal document,” Park said.
Though virtual visits may seem daunting, Park said doctors and patients are happy with this platform. He has been surveying his patients, and more than 92% indicated they are happy with the experience and would use telemedicine again.
Telemedicine may be an answer to providing care to the large and growing population of aging patients, especially in places experiencing specialty shortages.
Tips for conducting virtual visits
Dr Park offers the following tips to physicians so they can make the telemedicine experience satisfying for patients:
- Look in the mirror before going live; you do not want to have spinach in your teeth during an online visit.
- Look at the camera; patients need to know you are focusing on them.
- Make sure the room is front lit so patients see your face and not a shadow.
- Split the screen so patients appear on one half and their medical chart on the other.
- Review patients’ charts before the virtual visit to avoid spending too much time doing this while during the encounter.
- Have a good internet connection.
- Maintaining eye contact and giving full attention to patients goes a long way toward showing empathy and compassion.
