Enhanced web-side manner and digital inclusivity are key to maintaining telehealth momentum

The telehealth revolution—propelled by the coronavirus 2019 (COVID-19) pandemic after it was declared a public health emergency (PHE) in March 2020—provided physicians with the opportunity to integrate virtual care into their practices.¹ The U.S. government relaxed regulations, including the enforcement of some Health Insurance Portability and Accountability Act (HIPAA) restrictions, as Medicare expanded compensation for a range of telehealth services, allowing health care providers to essentially redefine the modern-day house call.

More than 75 percent of the respondents to a COVID-19 Healthcare Coalition survey conducted in July−August 2020 said they had used telehealth to provide quality care for COVID-19-related care, acute care, chronic disease management, hospital and emergency department follow-up, care coordination, and preventative care.²

For telehealth to continue its current trajectory, new approaches to virtual visits will need to be developed, as will strategies that support digital inclusivity for patients who lack access to appropriate technology and devices. Coverage and reimbursement for these services also will need to expand and gain permanence after the pandemic to facilitate the development of new technologies, such as artificial intelligence (AI)-video integration, to further the goal of providing safe, patient-centered, virtual care.

Benefits of virtual care

Medicare and Children’s Health Insurance Program patients received 34.5 million telehealth services in March−June 2020 during the first wave of the COVID-19 pandemic in the U.S.—a 2,600 percent increase from 2019, according to a report from the Centers for Medicare & Medicaid Services (CMS).³ This growth largely was the result of health care providers seeking ways to reduce nonessential office visits. As providers and patients became more comfortable with virtual care, benefits other than safety began to emerge, including accessibility, convenience, and reduced costs.

For a Clinical Congress 2020 session titled The Value of Time: Analysis of Surgical Post-Discharge Virtual vs. In-Person Visits, researchers analyzed how patients spend their time in postoperative virtual visits compared with face-to-face consultations.⁴ The study, which launched in August 2017 before the pandemic, tracked the time patients spent checking in, waiting to see the physician, meeting with the surgical team member, and checking out from in-person visits. On-site waiting time and an estimated drive time were factored into the overall time commitment.

The study showed that the total clinic time was longer for in-person visits than virtual visits (58 minutes versus 19 minutes); however, patients in both groups spent the same amount of time (8.3 versus 8.2 minutes) consulting with a member of their surgical team discussing their postoperative recovery (see Figure 1).⁴

FIGURE 1.

“The fact that that the amount of time spent with the surgery team member—around eight minutes—was the same for virtual and in-person visits should be really assuring to patients. They aren’t going to be spending less time with the health care provider in a virtual visit,” said lead study author Caroline Reinke, MD, FACS, associate professor of surgery, Atrium Health, Charlotte, NC.

The study design was a randomized controlled trial that involved more than 400 patients who underwent laparoscopic appendectomy or cholecystectomy at two hospitals in Charlotte and were randomized 2:1 to a post-discharge virtual visit or to an in-person visit.

The researchers also found that postoperative patients embraced the virtual scenario. The satisfaction rate between both groups of patients was similar (94 percent versus 98 percent).

“Telemedicine is a great way to check on your post-op patients,” said ACS Regent Anthony J. Atala, MD, FACS, director, Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, and coauthor of “Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic,” published in the April 2020 Journal of the American College of Surgeons. “Most postop care can be done via telemedicine in a much easier way for both the patient and the provider.”

“Frankly, if the patients are doing well, there’s really no reason for them to come back and see us,” said William C. Welch, MD, FACS, FAANS, FICS, FANOS, Chair, ACS Advisory Council for Neurological Surgery. “Yet, telemedicine allows us to have a discussion with our patients so that we can tell them about the next phase of their recovery. We can give them the prescriptions they may need for either medicine or physical therapy or other services, and it saves them the trip to come in. If they’re not doing well, it allows us to order what we believe are going to be the appropriate tests and then schedule an office visit.”

“A rapidly emerging and novel form of telemedicine that can be used in the post-discharge space is remote patient monitoring (RPM),” added Andrew R. Watson, MD, MLitt, FACS, FATA, a colorectal surgeon and past-president of the American Telemedicine Association. “Because RPM is asynchronous, you can respond to a text message or view a video or enter data, like temperature and blood sugar level, when you are ready,” he said, underscoring the convenience factor of virtual care.

Providers are seeing additional time-saving benefits of telehealth, according to Dr. Watson, including reduced no-show rates, the ability for clinicians to expand their practice without traveling to multiple hospitals and clinics, and, perhaps, diminished rates of burnout.

“Ultimately, developing a telepresence means providing enhanced patient-centered care,” said Dr. Reinke, “because you are reaching patients at the place where they are, rather than asking them to come to us. In our society, time is incredibly valuable—if you look at the amount of time that you save a patient, you can think about how that would translate into other areas of their lives in terms of being able to care for their children and other loved ones and to earn income to support their family.”

Challenges to universal implementation

The benefits of telemedicine are clear, but challenges to implementation remain. Developing enhanced communication best practices that overcome the barriers inherent to virtual care, establishing services that reduce digital exclusion and promote health equity, and advocating for expanded Medicare telehealth coverage and reimbursement are some of the hurdles that need to be addressed.

Communication

As a result of varying levels of Internet capacity, some virtual visits may experience dropped calls, time lags, and diminished image quality, which can affect the provider-patient experience.⁵ Even with strong Internet capability, the personal, human connection made during in-office visits can be missing in care provided via a digital platform. Consequently, it is essential to develop communication skills that will lead to a trusting relationship. Best practices for “web-side” communication include keeping the camera at eye level, modifying the clinician’s background to avoid visual distractions, employing body language and facial expressions that show interest and concern, and wearing professional attire.⁶

“Providers often want to look at the picture of the patient to feel like they’re looking them in the eyes and creating that connection virtually, but, in fact, many times, if you’re looking into the patient’s eyes on the screen, you’re actually looking away from them, and that is the way that they see it,” Dr. Reinke said. “Remember that looking into the camera is what’s going to let the patient know that you’re really engaged in the visit and with them and their questions.”

“It’s also important to say, ‘I’m going to take a moment here to review your pathology, and if you see me looking away from the camera, I’m looking at our electronic medical records so that I can pull this up and review it with you.’ This will help the patient understand that you’re not being distracted or doing other tasks during their visit, but instead you really are remaining focused on them,” she said.

Engaging in a slightly modified verbal communication style, speaking clearly and slowly, also is essential for a productive virtual encounter.

“The other issue that we get has to do with patients’ anxiety. As a result, we, as physicians and providers, have a tendency to interject, and that ruins the electronic communication,” said Dr. Welch, who sees about 20 percent of his patients virtually. “I’ve learned to get my sentences out in their completion and then just be quiet and listen to what the patient says and let them talk until they’re done talking. This is a slower or more deliberate mode of communication.”

Another component of establishing a good web-side manner is to support provider training to enhance familiarity with the equipment and virtual platform used during the virtual encounter. This training typically includes developing an understanding of how to troubleshoot for common problems, establishing alternate options to reach the patient in case an issue arises, and, of course, assessing the patient’s familiarity with telehealth and providing an overview prior to the virtual visit, if necessary.⁶

“We were able to deploy telemedicine within three days to our entire practice by doing an aggressive, team-based educational program for our providers and staff,” said Dr. Atala, who noted it took approximately one hour of in-person training for the team to learn how to implement telehealth visits at his facility. Educational handouts augmented the training, and a group trial run explored potential obstacles and solutions to video visits conducted through the patient portal. Physicians and staff completed 638 virtual visits within the first month of implementation.⁷

Emphasizing the HIPAA-approved confidentiality and privacy safeguards in place also are key to establishing trust. The ACS provides guidance for selecting telehealth vendors that support HIPAA-compliant video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype. Public-facing video communication applications, such as Facebook Live, Twitch, and TikTok, should not be used, according to these guidelines.⁸

Digital exclusion

To ensure telemedicine implementation does not deepen disparities in health care, systemwide steps should be taken to ensure access to vulnerable communities, including older adults, rural patients, Black and Latinx patients, and anyone who lacks access to a secure Internet connection. These steps include supporting digital literacy training, providing resources that offer access to video visits, and advocating for policies that mandate equitable access to telehealth.⁵

An estimated 42 million people, or 13 percent of the U.S. population, are without a high-speed Internet connection, according to an article published in the Journal of the American Medical Association.⁹ Nearly a third of households with incomes lower than $30,000 do not have access to a smartphone, and more than 40 percent do not have access to a computer or high-speed Internet—all of which are essential to virtual health care visits.⁹

“One of the challenges with telemedicine is to make sure that we do not overlook segments of our population who may not have the tools necessary to perform these types of telemedicine visits,” Dr. Atala said.

“Disparities in the provision of telemedicine is something we are watching very carefully,” Dr. Watson said. “This is a very real issue. Surgeons need to be proactive about how they use different types of telemedicine platforms and measure how well patients are able to use them.”

Bridging the digital divide is a work in progress. In an article published in the Boston Globe, Ajit Pai, Chairman of the Federal Communications Commission (FCC), noted that “the most crucial step in seizing the opportunities of digital medicine is making sure that every community has high-speed Internet access.”¹⁰ To that end, in September 2020 the FCC, U.S. Department of Health and Human Services, and U.S. Department of Agriculture announced a Memorandum of Understanding to work together on the Rural Telehealth Initiative aimed at addressing disparities, resolving service provider challenges, and promoting broadband services and technology in rural areas.¹¹

Medicare coverage and reimbursement

While telehealth often is used in reference to various virtual services that clinicians provide, the Medicare program has specific criteria that providers must meet for a service to be covered and reimbursed.¹² “Under the Medicare program, telehealth refers to an eligible service during which a patient and clinician interact in real time using a digital platform with two-way audio and video functionality,” said Patrick V. Bailey, MD, MLS, FACS, Medical Director, Advocacy, ACS Division of Advocacy and Health Policy.

CMS also pays for certain other services that are furnished remotely using telecommunications technology but are not considered Medicare telehealth services because they do not use a real-time audiovisual platform. According to Dr. Bailey, such services include audio-only evaluation and management (E/M) visits, physician interpretation of prerecorded imaging, and brief assessments performed via an online patient portal, telephone, or secure e-mail or text message.

“CMS revised, on an interim basis, requirements for the use of telehealth during the pandemic for the duration of the public health emergency in an effort to reduce exposure to COVID-19 and ensure continuity of care for Medicare beneficiaries,” Dr. Bailey said. CMS maintains a comprehensive list of telehealth services that may be furnished under the Medicare Physician Fee Schedule (MPFS) during the PHE. Table 1 outlines the temporary changes to telehealth rules under the MPFS during the COVID-19 PHE.¹³

TABLE 1. TEMPORARY CHANGES TO TELEHEALTH RULES UNDER THE MPFS DURING THE COVID-19 PHE

“During the PHE, Medicare pays the same amount for telehealth services as it would if the service were furnished in person. Physicians who bill for Medicare telehealth services should report the place of service (POS) code that would have been reported had the service been furnished in person,” Dr. Bailey said. Modifier 95 (Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system) should be appended to claim lines that describe services furnished via telehealth. Modifier 95 and Modifier CS both should be appended when COVID-19 testing-related services are furnished via a telehealth E/M visit. The CS modifier is used to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and indicates that the claim should be reimbursed at 100 percent, including the amount that would have been paid by the patient.

Under its current policy, CMS adds services to the MPFS telehealth services list when it determines that they are similar to telehealth services that are already eligible for Medicare coverage. The ACS has noted in comments to CMS that, when making these additions, the agency does not address the inherent differences in the provision of an in-person versus telehealth service, such as physician work, clinical staff time, and supplies and equipment.¹⁴ These same differences also may vary across various telehealth services and the platforms used to furnish them. To account for these differences and ensure that codes on the Medicare telehealth list reflect the applicable underlying service and the appropriate inputs needed to provide such services, the ACS continues to urge CMS to create new, corresponding telehealth codes for each face-to-face code added to the Medicare telehealth list.

The College has developed a series of tools to help surgeons navigate and integrate virtual services into their practices and enhance their ability to safely care for patients during the PHE. The ACS COVID-19 Telehealth Resource Center includes guidance on coverage, coding, and payment rules for virtual services from both Medicare and private payors, HIPAA privacy and security rules applicable to telehealth during the PHE, and various telehealth products available to physicians.

The future of telehealth technology

Telehealth can enhance timely, convenient, and resource-preserving care from a safe distance, but when combined with AI virtual care, it could evolve into a powerful public health resource.¹⁵

“AI will be a tool that helps us understand the near real-time data we are getting from telemedicine visits and remote patient monitoring (RPM) data in particular,” said Dr. Watson, underscoring the need for RPM and video visits to become more integrated with improved functionality. RPM tools, including smartphones, blood pressure cuffs, and pulse oximeters, allow patients to self-monitor their symptoms and offer providers the opportunity to view real-time data.¹⁶ This technology encourages patients to play an active role in their own care and alerts clinicians to potential problems before complications arise. Incorporating patient-generated data with AI offers physicians prescreening capabilities that could reduce in-person visits. According to the Telehealth Impact Physician Survey, 11 percent of respondents have used RPM technology.²

Expanded deployment of triage bots also will play a role in telemedicine’s evolution. “We saw this in the COVID-era, where chat bots helped us screen large segments of the population to see who might need to be monitored or who actually might need a video visit,” said Dr. Watson. “Chat bots are an efficient triage engine because they help ensure physicians are not spending precious time on a video call.”

Advances in telehealth solutions are key components of the digital transformation in health care and will continue to play an essential role in patient outcomes, particularly as patients and providers become more adept at using these technologies. As with almost any major health care innovation, challenges related to implementation and consumer adoption will need to be addressed, as will issues related to coverage and regulatory mandates.

Conclusion

The COVID-19 crisis was a catalyst for expediting telehealth services because of the safety, accessibility, and efficacy these modalities offer. To maintain the momentum behind virtual care adoption, it is important to develop new communication strategies that enhance web-side manner, and to create inclusive systems that meet the needs of marginalized communities that may lack access to, or a working knowledge of, digital health care technology. Although these considerations are key to telehealth expansion, ultimately, the future of virtual care likely will depend on reimbursement for these services. As these challenges are met, this technology will continue to redefine how patient-centered care is delivered.

Acknowledgment

Lauren M. Foe, MPH, Senior Regulatory Associate, ACS Division of Advocacy and Health Policy, Washington, DC, contributed to the Medicare coverage and reimbursement section of this article.

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