Re: Across The Hall Nm Facile Epub Download Forum
Julia Heaslet
Telemedicine is a rapidly accelerating new avenue for delivering health care services. Although introduced decades ago, adoption and integration into surgical care has been slower than in other medical disciplines. Guidelines for the use of telemedicine in surgery have existed since the early 2000s,1 but the coronavirus 2019 (COVID-19) pandemic brought a new urgency to providing continued access to safe, socially distanced care. Changes in the regulatory environment, available platforms, and new opportunities for billing and reimbursement have facilitated a tremendous increase in the use of video visits, remote patient monitoring, and even telephone visits.
As surgeons and health systems rapidly expanded care delivery using telemedicine technology, we determined the need for just-in-time education for both surgical patients and professionals. How do we deliver high-quality surgical care via telehealth? What are the barriers to implementation, and how can we integrate this approach into value-based care delivery models? How do we balance convenience and accessibility, setting expectations for new communication channels with patients? What are new ways to conduct patient examinations using telemedicine?
In this article, we discuss the evolving standards for pre- and postoperative video visits, the requirements for operational implementation, the evolving reimbursement landscape, and regulatory considerations. We also explore the innovations that telemedicine brings to outpatient care and surgical decision-making. Finally, we explore how the American College of Surgeons (ACS) can support surgeons who want to adopt telemedicine in their practice, advocate for the legislation and regulatory reforms required to allow surgeons to serve the greatest number of patients, and foster inclusiveness and continuity of high-quality patient care.
Before the COVID-19 pandemic, telemedicine was used primarily to facilitate preoperative care when in-person care was difficult because of diminished access to local care providers, such as in rural areas. Shifting portions of preoperative care to telemedicine minimizes patient transportation challenges, avoids work or school absences, and protects providers and patients by minimizing exposure to disease.
Some specific examinations should be performed in-person preoperatively (for example, a rectal exam before rectal surgery), but much can be accomplished via virtual consultation. For patients isolated geographically from surgical services, virtual presenters can perform a surrogate examination and help present a patient to the surgeon. They can palpate the abdomen, listen to the heart and lungs, and relay their findings, all without requiring the patient to travel to a specific location.
Like video conferencing software in general, many telemedicine platforms allow screen sharing. Images and other data from the electronic health record (EHR) can be reviewed with patients to demonstrate findings and discuss operative planning. Some platforms also provide the ability to document informed consent with electronic signature or video recording. Regardless of the specific content of the preoperative visit, it is imperative to plan ahead for the kind of data that will be reviewed and discussed with the patient, and to prepare the patient for the length and content of the discussion. Adoption of these virtual visit practices represents a significant cultural change in surgery, but we have negotiated radical evolution in practice before, such as with the adoption of laparoscopy.
A recent randomized controlled trial demonstrated that postoperative virtual visits following urgent minimally invasive surgery were more convenient for patients and not associated with higher post-discharge care use than in-person follow-up visits.
It may be necessary to prepare patients for awkward examinations. Patients who are uncomfortable sharing a physical finding live on video can send a photograph via the secure patient portal. They may even need to ask a family member or caregiver for assistance in taking the photograph. The image then can be reviewed during the visit with the patient and incorporated into the note documenting the visit. For tips on facilitating virtual visits, see Table 1.
Institutional and user-related factors may obstruct adoption of telemedicine and integration into an existing workflow.3 Examples of barriers that can be traced back to the practice or health care facility include cost of implementation, reimbursement clarity, legal liability, privacy and confidentiality concerns, and data security. Older patients typically experience more challenges in adapting to telehealth communications and may need to rely on caregivers who are more facile with digital technology, but as individuals who routinely use this technology age, this challenge will fade.
Other patient-associated factors associated with adoption include level of education, eHealth or computer literacy, bandwidth of dwelling, and lack of awareness of the existence of several telemedicine products and services. Being technically challenged, resistance to change, lack of licensing, and perceptions of impersonal care ranked among the most frequent staffing-associated challenges for integrating telemedicine into existing work processes. Hardware requirements, Wi-Fi service, and telecommunication-related troubleshooting affect vulnerable populations disproportionately. Elderly, low-income, minority, non-English speakers, and individuals living in rural areas may have more difficulty connecting to providers via telehealth. Even with adequate service, patients may be unfamiliar or frustrated with software installation, e-mail links, patient portal messaging, and password protection.
One potential solution is the collaboration with a third party such as a community pharmacy or urgent care center. Health care systems and practices also might consider establishing information technology service support for their patients, as patients become increasingly important users of the health information software. These local experts can provide the designated area for the telecommunication platform and assistance with the virtual clinical visit.
Translation services must be available while using telemedicine for both pre- and postoperative care, and multiple platforms offer real-time translation via three-way video visits. Overwhelmingly, available bandwidth is a problem, especially in rural and underserved urban areas. Poor bandwidth can lead to frozen video or a discrepancy between audio and video that may limit the examination or overall consultation. The Federal Communications Commission (FCC) has released significant grant funding to overcome some of these challenges.
A clear workflow is vital to maximize the value of telehealth service.4 Scheduling protocols and patient-facing scripts should be created to facilitate the identification of appropriate clinical use cases and patients who would have the most successful virtual visits. Inclusion and exclusion criteria for virtual visits should be created for office staff and schedulers. Templates with block time for telehealth visits should account for the time needed to complete pre-visit staff communications, patient education for connection, and inevitable connection failures.
Clinicians and billing and coding staff should be aware of the language required to sufficiently document virtual encounters, remote patient monitoring, and other telemedicine services. New Current Procedural Terminology (CPT) codes are available for telehealth reimbursement, and these codes and their appropriate modifiers should be integrated into the EHR.* The available technology should be able to capture and record any necessary patient signatures and consents, including practice privacy notices. The new evaluation and management (E/M) policies that took effect in January now base billing on time and complexity, which removes the documentation barriers of the cumbersome review of symptoms and mandatory multisystem examination. This change represents a significant step forward for telemedicine billing. Some special provisions are in place for billing and coding during the COVID-19 pandemic, and it is unclear how long these policies will endure.5
Hardware requirements exist for both the provider and the patient. Successful video telehealth encounters require devices such as a cellular- or Wi-Fi-enabled smartphone or tablet, desktop computer with a webcam and microphone, or laptop computer with integrated camera and microphone. Platforms such as MyChart, Doximity, FaceTime, Zoom, and Skype facilitate the virtual encounter. Some of these platforms now can be used under the Public Health Emergency (PHE) set to expire in late April 2021.
Having the hardware and software infrastructure in place will be worthwhile only if ongoing training and technology support is available to the users. Provider and staff training, coding and billing integration, institutional information technology support, and lastly, but most importantly, patient and caretaker education are critical to successful adoption and durable implementation (see Figure 1).
New visit billing has been greatly facilitated by the January 2021 E/M billing changes. Reimbursement is now based on time and complexity alone, and the cumbersome review of systems and specific examination requirements have been removed; both of these changes are particularly impactful in telemedicine billing. The COVID-19 pandemic experience confirmed that remote encounters facilitated via audiovisual technology can count toward the postoperative visit. These visits fall under the global period and, therefore, are not billable events. This situation always has and will continue to represent a real opportunity for telemedicine growth after surgical care. The PHE telephone waiver is in place so that audio-only visits are possible, but many expect the telephone-only provision to be discontinued when the PHE expires.
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