Healthcare systems and governments in the United States and much of world have had to take unprecedented emergency measures to contain the COVID-19 pandemic. Social distancing has been a key component of the effort to prevent person-to-person transmission of SARS-CoV-2, the novel coronavirus that causes the disease. Indeed, governors of most states have ordered non-essential businesses to remain closed and residents to stay at home. Medical practices have postponed elective procedures and cancelled non-urgent face-to-face patient encounters. Healthcare providers en masse have replaced office visits with telemedicine encounters, giving them a way to provide care without putting patients and themselves at risk of infection. Depending on a number of factors, including how providers and patients rate their experience with virtual encounters, the pandemic may propel telemedicine into a more integral role in medical practice going forward.

“Telemedicine is assuming tsunami-like growth and has reached the critical mass where patients will expect that their provider will be able to conduct a virtual visit,” said Neil Baum, MD, Professor of Clinical Urology at Tulane Medical School in New Orleans, a proponent of virtual medicine. “Practices that don’t offer telemedicine will find that patients will seek out a provider who does offer this service.”

Benefits

Telemedicine can enable urologists to improve access to their practices, reduce costs, enhance productivity, improve patient satisfaction, and perhaps reduce the high rate of physician burnout, Dr Baum said. “I would like to think that this COVID-19 crisis has opened up a new way for the urologist to implement telemedicine into their practices,” he told Renal & Urology News.


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Only a few years ago, the use of telemedicine was relegated to treating patients in rural areas or patients who were far from “bricks and mortar practices,” Dr Baum said. The COVID-19 crisis and relaxation of Centers for Medicare and Medicaid Services (CMS) requirements for conducting telemedicine have made this modality attractive to urologists. “Now urologists can treat patients 24/7 from their homes using laptops and even mobile devices to communicate with patients, Dr Baum said. “What was once done using a telephone is now accomplished using synchronous audiovisual communication.”

Nephrology practices also have greatly expanded their use of telemedicine, which provides a safer way to care for patients with end-stage renal disease (ESRD). This patient population is at high risk of contracting infections and suffering severe complications from them as a result of underlying health problems.

“Health professionals across the US are witnessing a radical transformation from in-person face-to-face care to virtual as we strive to decrease the transmission of COVID-19 to healthcare professionals and ESRD patients,” nephrologist Martin J. Schreiber, MD, Chief Medical Officer for DaVita Home Modalities, said in an April 9 webinar produced by the American Society of Nephrology (ASN). “We are seeing great telehealth adoption that would previously take years to advance, now occurring in literally weeks.”

Despite “myths” that virtual health is too difficult or not effective or that patients prefer in-person encounters, “we now see that COVID has proved to be the ultimate virtual health myth buster,” Dr Schreiber added.

Virtual visits skyrocket

At DaVita Inc., one of the two major providers of dialysis care in the United States, total telemedicine appointments rose by 950% from before the COVID-19 pandemic to April 3, Dr Schreiber reported. Between the time before the pandemic and March, the percentage of physician visits completed via telemedicine rose by 659%. Fresenius Medical Care North America, the other major dialysis provider, reported that its telemedicine workflow grew by 7000 virtual visits in the 2 weeks prior to April 6.

At Integrated Medical Professionals, a Farmingdale, New York-based independent urology group of more than 100 providers and a clinical affiliate of The Mount Sinai Health System in New York City, 73% of medical encounters in the week ending April 17 were via telemedicine and 27% were office visits, according to data provided by the group’s chairman and CEO Deepak A. Kapoor, MD. By comparison, for the week beginning March 9, all medical encounters were office visits.

“Certainly, we can anticipate that for some patients there will be a great appetite to continue the [telemedicine] services,” Dr Kapoor said. “Whether we can and will do so depends largely on behavioral changes in the patient population and guidance from regulatory bodies.”

“Telemedicine has become huge,” said nephrologist Rajiv Agarwal, MD, MS, Professor of Medicine at Indiana University School of Medicine in Indianapolis. “It is the primary way we are seeing our patients.” He estimates that 90% of medical encounters are now telemedicine visits.

Dr Agarwal authored an editorial in Nephrology Dialysis Transplantation in which he observed that most routine medical services were suspended in response to the pandemic, leaving patients with chronic illnesses exposed to potential harm because of a lack of access to routine medical care. “COVID-19 was pushing all other diseases by the wayside, and telemedicine rapidly emerged,” Dr Agarwal wrote. “Many of the rules [regarding telemedicine use] that would have taken years to be approved were passed almost overnight.”

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Jeffrey Giullian, MD, Chief Medical Officer at DaVita, said the pandemic has been “a catalyst for telehealth adoption” by physicians and home dialysis patients. “This is especially pertinent at this time when limiting exposure to others will increase safety measures for all our patients, teammates and physicians. Even before the [Trump] Administration’s most recent effort to enable telehealth, we provided home patients the opportunity to engage in our platform, DaVita Care Connect, to continually support their health and well-being at home.”

“We expedited the rollout of telemedicine technology in our centers to enable more virtual visits for our home and in-center patients,” said Jeffrey Hymes, MD, Chief Medical Officer for Fresenius Kidney Care. “This included creating updated policies, training, and support lines as quickly as possible. We have now logged more than 50,000 remote visits in just the past month between our patients, care teams, and physicians. This is an incredible increase and a direct response to demand for more telemedicine, facilitated by waivers from CMS that allow for reimbursement. We hope that as patients and caregivers become more comfortable and familiar with the technology, there will be further adoption of telemedicine when we return to regular operations.”

CMS waivers

Among other waivers, CMS has relaxed the requirement for monthly in-person visits if patients are considered stable and use of telemedicine is being recommended to ensure patient safety, Jeffrey Silberzweig, MD, Co-Chair of the ASN’s COVID-19 Response Team, noted in the webinar. In addition, licensed professionals may practice across state lines if they have an equivalent license from another state and are not “affirmatively barred” from practice in that state, and that state has no law prohibiting practice across state lines.

CPT codes have been expanded so that it is possible to bill patients for services and be compensated appropriately, Dr Baum said. “If we look at the glass as half full, we can conclude that this coronavirus crisis has provided us with an opportunity,” he said. He said he predicts that the current relaxation of CMS guidelines for telemedicine will probably be rescinded when the crisis has abated.

Implementation

Despite a promising outlook for telemedicine, barriers to implementation exist. “Of course, there is concern about the cost and the complexity of implementation of telemedicine technology,” Dr Baum pointed out. Unfortunately, he noted, the history of the implementation of electronic medical records (EMRs) has left a bitter taste in the urologic community. “EMRs were complicated, expensive, and often resulted in a loss of productivity as the learning curve was so steep that doctors had to decrease the number of patients seen before becoming comfortable with the conversion from paper to electronic records,” he said. “Telemedicine implementation is much less onerous and much less expensive.”

Telemedicine is available as a cloud-based platform that requires less IT support and less hardware and software management, he said. The technology required for patients to participate in telemedicine is nearly ubiquitous, and most patients, including seniors, have smartphones or access to a computer.