COVID-19
A Primer on Telemedicine During the COVID-19 Pandemic
By Elliot J. Krane, MD
Professor, Departments of Anesthesiology, Perioperative & Pain Medicine, and Pediatrics
Stanford University School of Medicine
The SARS Coronavirus-2 viral pandemic is sweeping through our nation and the world, and the worst may be yet to come. Mandatory social distancing and a shortage of personal protective equipment have led many medical providers to close clinics and to curtail surgical and interventional procedures, which already has created collateral morbidity added to the unprecedented numbers of victims of this pandemic. Telemedicine offers both clinics and inpatient physicians a method to continue to see and treat patients, and provide some degree of continuity of care, which, while not ideal in scope and comprehensiveness, is still substantially better than no care at all. I hope in this essay to describe the process of how this was instituted in our pain management practice, and my institution as a whole, and to offer a few commonsense tips for success as well as some “pro tips” for those who may wish to up their game.
The Pediatric Pain Management Clinic at Stanford Children’s Health has been making use of telemedicine or telehealth for more than two years to provide both medical and mental health follow-up care to patients living some distance from Palo Alto. Approximately 10% of our visits were via telemedicine prior to March 2020. Then the pandemic came to Northern California.
On March 6, 2020, Stanford Healthcare announced that an outpatient clinic physician tested positive for COVID-19. It became clear to me that it was imperative to immediately move our clinic to a 100% telemedicine basis in order to protect not only our providers and staff, but also our patients and their families from possible exposure in our small waiting room and examination rooms. Further, many of our patients are immunocompromised, and many others travel to our pain clinic with a grandparent who accompanies them to allow the child’s working parents to remain at their places of employment. Thus, it was also imperative not to expose these older and high-risk family members to this potentially life-threatening infection.
Twenty-four hours after our clinical group endorsed this decision, our clinic support staff worked all weekend telephoning patients to notify them of this change, which was almost unanimously met with relief and gratitude.
Because our staff and providers were previously trained and certified for telemedicine by the institution, this transition was as smooth and efficient as flipping a switch.
Telemedicine from Home
Additionally, all of our providers preferred to conduct their clinics from home rather than travel to our physical clinic, and this necessitated our IT department to conduct a video conference with each provider to confirm their home had adequate bandwidth as well as security. That task was accomplished the very next business day with remarkable alacrity.
In the ensuing weeks, virtually every clinic at both Stanford Children’s Health and Stanford Healthcare transitioned to an all telehealth basis for patient care. The transformation was enormous: in the 29 days of February 2020 there were a total of 1,000 telemedicine visits at Stanford. By April 2020 there were 3,000 virtual visits per day.
Telemedicine New Patient Evaluations
Our first challenge was to have a method for a multidisciplinary evaluation with as many as three providers, plus one parent and one patient to interact simultaneously, and Zoom was the only platform suitable for this. While our electronic health record, EPIC, has a Telehealth video function, it is one that only allows for a 1:1 interaction between one provider and one patient. While EPIC is building a version of their software to allow multiple simultaneous users, that feature has not been widely released yet and its functionality and stability are yet to be seen.
For every new patient multidisciplinary pain evaluation, our clinic support staff creates three password restricted Zoom meetings that are routed through Stanford’s encrypted servers: one for the providers alone to use to huddle before and after the evaluation, one for all participants to use for obtaining the history as a group, and one for our psychologist to use privately with the patient and then with the patient for a mental health assessment. Obviously, a full physical examination (PE) is impossible on video, but it is surprising what one can indeed accomplish.
For example, a PE of a typical new headache patient is frequently redundant. Headache patients are generally referred to us by a neurologist who has performed several neurological and fundoscopic examinations and has already obtained brain imaging to rule out mass lesions (which are the most common childhood solid tumors). Nevertheless, it is still possible on video to evaluate cranial nerve function, rule out pronator drift and involuntary movements, observe muscle bulk, range of motion, assess cerebellar function and gait, and test lower extremity strength with floor squats, toe-walking and heel walks!
The PE for CRPS is similarly feasible by observing the color of the affected limb and normal limb on video, gait if pain effects the lower extremity as is almost always the case in childhood CRPS, asymmetric muscle bulk, and to ask a parent to demonstrate the presence of allodynia by touching or blowing on the affected limb to assess allodynia. It takes some creativity and flexibility on the part of the provider and acceptance and consent on the part of the patient but in many if not most cases, an adequate physical examination may be obtained.
Telemedicine Follow-up Appointments
Providing follow-up pain management visits by telemedicine is not a difficult task. Most of our follow-up care involves medication management and psychotherapy, and both are easily achieved by telemedicine.
For both new and follow-up patients, there are going to be occasions in which there is no substitute for a hands-on physical examination, and if a provider believes that such is indicated and is sufficiently urgent, we will of course see the patient in the clinic. After three months of providing telemedicine appointments, this has very rarely been necessary.
Technology and HIPAA
The EPIC electronic medical record currently in use at Stanford has a telehealth module that is both secure and HIPAA-compliant. This was usually used by us prior to the COVID-19 pandemic. However, we have found that its bandwidth is inadequate, especially when many clinics simultaneously use EPIC telehealth, and as mentioned above, EPIC does not allow a multi-user experience. We have therefore turned to Zoom, using a secure Stanford server and end-to-end encryption to maintain HIPAA compliance.
You may then ask how one can initiate telehealth if one does not have IT support and university infrastructure for secure encrypted internet video. The answer is, the Department of Health and Human Services (HHS) announced that in order to facilitate wide use of telemedicine during the pandemic, all HIPAA enforcement is waived indefinitely, and that almost any video platform would be acceptable including FaceTime, Skype, Zoom, WebEx, Facebook Messenger video chat, and Google Hangouts video. Under this Notice, however, it is noted that some video links such as Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telemedicine by covered health care providers.
Billing and Reimbursement
In California, both Medi-Cal and private insurers must reimburse for telemedicine care provided by live video. In October 2019, Governor Newsom signed into law AB 744, which mandates that payers reimburse healthcare providers for telehealth services “on the same basis and to the same extent” as they cover in-person services, making California one of roughly a dozen states that require payment parity. As of January 2020, Aetna became the last holdout insurer to come into compliance with this law.
Conventional E&M billing codes are based upon completing key elements of the medical history, physical examination and case planning, and appropriate documentation of the same. Because any telemedicine visit cannot check the boxes of a thorough physical examination, one may still bill the usual codes but based upon face-to-face time spent with the patient (and their parent) provided at least 50% of the time is used for case planning and counseling, which is generally the case in a pain clinic. There are no special codes for telemedicine, but a GT modifier is inserted in front of the CPT codes typically used for in-person E&M services.
Telemedicine sessions may be originated from any site including the home of the provider to any site including the home of the patient according to California law. However, Medicare places geographic restrictions on the origin of the telehealth session, which is to say it must be the provider’s location. For details see http://caltrc.org/wp-content/uploads/2019/04/Reimbursement-Guide-May-2019.pdf. Of course, very few pediatric patients are insured through Medicare.
Consent
California law states that the provider at the originating site must obtain and document oral or written consent before performing any telemedicine services (California Health & Safety Code Sec. 2290.5). The following is the text that I place at the top of every clinic note in which services are provided by telemedicine:
“This consultation was performed with the use of secure and encrypted videoconferencing equipment with a trained telehealth presenter. The participating parent understands that the reason for the telehealth evaluation was to protect patients, families and staff during the SARS-Coronavirus-2 epidemic and that the evaluation precluded a personal physical examination; this might be recommended at the discretion of the provider. The alternative to a telehealth evaluation at this time would be a personal conventional evaluation weeks or months from now. The potential risks and benefits of the telehealth session were discussed with the patient and/or family, who then verbally consented to participate.”
Tips, Do’s, and Don’ts:
- Remember that even though you may be initiating the telemedicine session from your home, you and your environment should appear professional. Athletic clothes, unshaven faces, unkempt hair, etc. are no more appropriate on video with a patient than in the clinic.
- Conduct your video session in a quiet space away from loud housemates and barking dogs. Keep the windows closed to block the noise of traffic, sirens, leaf blowers, and neighborhood children playing Marco Polo.
- Think about the background the patient will see behind you. A bedroom, kitchen or untidy space is probably unprofessional. Best is a neutrally colored wall, perhaps with a floor plant or drapery. If you do not have such a background, resist the temptation to use a Zoom virtual background - save those for family and friend Zoom meetings. Virtual backgrounds looked cool back in February and March when they were a novelty, but now they are old and distracting. Instead, one can purchase neutral video backdrop and stand for about $50 from a photo supplier or Amazon (https://amzn.to/2yX81Bj). On the other hand, your patient will probably not think about their background and you will likely have the opportunity to peer into your patient’s home, which may provide some useful social information to add to your database.
- If using Zoom, always go into Settings and switch on “Touch Up My Appearance.”
- If your patient’s bandwidth is not optimal and they are using a smart phone or pad, ask them to switch to cellular communication instead of Wi-Fi. As a last resort you can switch audio to phones while you use the computer only for video. And if you have to bail on video, you can still bill for the entire session as a telehealth even if nearly all the session was on the telephone, provided that it was initiated with video and you actually saw your patient if even for a minute.
- Mute your computer’s microphone while you are not talking. On Zoom, if you mute the microphone you need only press and hold the space bar while you talk to unmute it, rather than continually turning mute on and off.
Pro Tips:
- Perhaps you are as tired as I am of laptops on desks with the camera pointed up, providing a direct line of sight to the turbinates of the other person on Zoom. This is about your webcam angle. Your computer camera should be slightly higher than your eyes and pointed down. If you are using a laptop or iPad, place it upon a laptop stand (https://amzn.to/2yRzKDB) or a stack of books.
- The image quality of webcams built into laptop and desktop computers is truly awful. To up your game, you can purchase a webcam (https://nyti.ms/2yQT8k5), but these are all on backorder these days because of the surge in demand for them at the outset of the pandemic. But if you have a digital camera or a video camera such as a GoPro with an HDMI video output, you can plug in a micro-HDMI cable into your camera output, plug that into a HDMI video capture card (https://amzn.to/2XMK2x7) and then into your USB input on your computer. Set your camera on video, use a focal length of about 50mm (equivalent to 80mm on a 35mm camera), open the aperture as wide as it goes and the shutter speed at twice your frame rate, and set ISO to auto. Put your computer on a tripod behind your computer (remember lens just about your eye level), tell Zoom you are using the camera for input, and you’ll be very pleased at the result. For Youtube videos describing how to use a digital camera as a webcam for Zoom and other web meetings, see: https://bit.ly/2BcHyjV, https://bit.ly/3gQs1XA and https://bit.ly/3cnhYWu.
- Similarly, lighting should come from in front of you, and ideally from below your face. Lighting from above, such as a ceiling fixture, will cast unattractive shadows on your face and highlight furrows and wrinkles. One trick is to place a lamp adjacent to your computer screen, and white paper on the table in front of you to reflect its light upward.
Telemedicine offers providers and patients a method for continuing medical care in this unprecedented time. Whether it will remain an alternative for routine new patient and follow-up care is to be seen, but I suspect that both physicians and patients, once familiar with the technology, will opt to use it much more in the future than it has been utilized in the past.
