Photo: Summus Global
At the start of the pandemic, emergency declarations and insurer policies encouraged the shift to telehealth. Telehealth usage has skyrocketed, often leading patients to grow accustomed to relying on virtual care for its convenience and cost-efficiency.
Now, as states across the U.S. are putting an end to these policies, telehealth meets one of its biggest hurdles: geographic barriers.
Dr. Mary Mulcare, chief medical officer at telehealth technology company Summus Global and an emergency medicine physician at New York-Presbyterian and Weill Cornell Medicine, has been on the front lines of the pandemic. She's seen firsthand how both physicians and patients have adjusted their expectations and processes around virtual care.
Healthcare IT News interviewed Mulcare to dig into the reversion to pre-pandemic regulations, the ethics of telemedicine across state lines, what telehealth technologies can do to increase access, and more.
Q. Regarding the future of telehealth after the pandemic, what will be the impact of the reversion to pre-pandemic regulations on both providers and patients if Congress and the states do not act?
A. There are several ways in which regulatory relaxations have allowed telemedicine to soar during the pandemic: HIPAA flexibility, telemedicine waivers through CMS, cost-sharing, and billing and reimbursement changes. While some of these might reasonably be retightened to pre-pandemic levels to improve the delivery of care via this modality, reverting to prior with others would inhibit the progress we have made.
Telehealth is a resource that allows patients to access high-quality, experienced physicians across geographic lines or avoid having to travel for a visit. The breakdown of geographic barriers, and specifically the change allowing providers to practice across state lines, independently from the state(s) in which they are currently licensed, has been an exceedingly valuable step in the right direction.
It would be a shame for that to dissolve. The general practice of medicine is not defined by state lines. To take this a step further, physicians are different from lawyers, for example. Each state has its own bar and legal text as to which lawyers need to be adept for that state. The practice of medicine, on the contrary, is not state-specific but rather can be defined by the experience of providers and resources available.
What is at stake if this goes back to the way it was and physicians are bound to treat only patients physically present in the state in which they are licensed? There will be lost opportunities for patients to achieve the health outcomes they are motivated to or need to obtain.
Some patients have specialized needs that historically have required a lot of travel, time and money. The economic impact of health issues for these families and their quality of life has improved while still allowing them to access their doctors on a regular basis.
One of the changes during the pandemic was around the type of communication apps allowed to conduct visits. The need to utilize a HIPAA-compliant platform became less important than allowing people to access care, which in my opinion was a good trade. Now as we look to telehealth as a permanent part of the spectrum of care, we do need to be careful that people's private health information is protected and secure.
Re-imposing regulatory systems around platforms is valuable for both patients and providers to avoid accidental missteps as we enter a new paradigm with virtual care very much in the mix.
Q. How will physicians and patients approach telemedicine care across state lines ethically?
A. The good news is that the Hippocratic Oath is consistent across the country and across care-delivery modalities. Thus, physicians should be maintaining the same ethical code of conduct regardless of where or how they are seeing patients.
If state lines are upheld, we may see increasing situations where patients drive across state lines to have a telemedicine visit from a rest stop. The value, comfort and convenience of a telemedicine visit is then mostly lost.
Doing a physical exam on a patient in a car is more limited. The patient may not have brought their pill bottles with them. They may not have remote monitoring equipment with them to help get a set of vital signs. All that would have been present potentially in their home. And the point of practicing within a state seems to have been missed.
The challenge for providers of working across state lines and into different geographic regions is understanding social stressors and resources present in those areas. For example, asking a patient to go to a local pharmacy across the street in an urban setting is very different from giving someone similar instructions who lives 50 miles driving distance from the nearest pharmacy.
As physicians approach treating a patient from regions that are new to them, there also may be different cultural considerations to be taken into account. Different ethnic groups tend to cluster in different areas of the country, and providers in that space are often very familiar with the preferences of each community.
Ultimately, this can be mitigated with education of the telemedicine providers for effective communication techniques and situational awareness. We can also educate patients regarding self-advocacy and raising important concerns with their provider. The balance seems to tip toward community members being provided enhanced access to care rather than waiting or delaying their care due to limited availability.
Q. You've talked about the importance of telehealth for medicine reconciliation and how this critically impacts the geriatric community. Please elaborate.
A. One of the powers of telehealth is that it allows providers into the patient's home. We get a better sense of some of the challenges or supports a patient may have, which is lost in a sterile office setting.
This is especially valuable for older adults and those who may have trouble communicating or have cognitive impairment. This is also exceedingly valuable for all patient ages with complicated, chronic medical conditions requiring significant medical and pharmacological support.
First, it allows caregivers for the patient to more easily join the conversation when appropriate. Many older adults have multiple caregivers between family and external help, and not all caregivers can be present at an in-person visit.
This has been especially true during the pandemic when additional people present in any medical setting has been strongly discouraged. These caregivers are valuable in providing collateral information and helping us understand what is going on "behind the scenes."
Second, there are certain activities, such as medication reconciliation, which should take place during a medical visit that are dramatically facilitated by patients being in their home environment. How many people remember to bring all their pill bottles to an office visit to be able to accurately display what they are taking on a daily basis for medication reconciliation? Not many.
Some may bring their pill boxes where the medication for the week has already been dispensed by a caregiver into individual, day-specific containers. While possible to do, it takes a lot of time to try and identify each pill individually, comparing each pill to pictures online and available taxonomies of identifiable features, to record what the patient is taking. Physicians are not granted that time in the current model of office visits with our healthcare system.
Telehealth allows providers to see the home environment directly: review each pill bottle and ask the patient whether they are taking it and how often, make sure the patient has enough of the needed medication and then provide timely refills, and have the patient discard expired or no longer needed medications so that there isn't confusion going forward. Allowing the patient and caregiver to look at the medications in real time while doing this also reinforces any education needed around medication safety and delivery.
Speaking of safety, the provider's view into the home also allows for education around fall prevention for older adults and other patients at risk. The provider may see a lack of handrails in key locations or multiple area rugs that are known to cause falls. The provider may also watch the patient use the walker or other home assist devices to give recommendations as to whether they are being used correctly.
Q. When the pandemic is over, what can virtual care platforms do to help increase access and break down geographic barriers to improve patient outcomes?
A. Virtual care companies should strive toward easy-to-use platforms that are HIPAA-compliant and truly facilitate physician-patient interaction. Outcomes will be reflected in those solutions with high-quality products. People will save time and money while attaining better health when taking part in a seamless connection to the medical world.
Patient outcomes will also improve with access to high-quality providers who can relate to specialized needs and are curated to handle a patient's specific concern. People need to be aware of the different options they have available to them in the virtual healthcare world and not be afraid to take advantage of the opportunity.
Having a digital gateway to care is exceedingly valuable, yet understandably foreign to many. We need to raise awareness of the access points now available.
With the pandemic, telehealth passed a significant stress test for what it can do and how useful it can be. Physicians have harnessed the technology similarly to patients. Thus, patients shouldn't feel that they will be reaching providers in a less preferred manner.
Physicians and other providers have seen the benefit and convenience of practicing medicine when possible in this manner. Of course there will be times when in-person care is preferable, and we are now becoming able to understand that balance.
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.
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