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Telemedicine in Primary Care

December 10, 2020

The COVID-19 pandemic has forced us all to alter our approach to patient care. A year ago, both we and our patients had the expectation that in most of our interactions we would be in the same room touching and being touched. It was only in the most unusual circumstances that we would need physical barriers to protect the health of one another. Telemedicine has a century-long history of evolution, but the infrastructure for real-time broadband communication between providers and patients has only become widespread in the US over the past two decades. The pandemic has driven a rapid conversion of many interventions traditionally done in the office setting to diagnostic and therapeutic interventions using tools with which most of us have had no training and for which standards of practice are not yet determined.

Fortunately, there is now a significant body of empirical evidence of what clinical work can be done using communications technology and what the technical requirements are to perform it. Much of the research has been funded by federal agencies e.g., National Library of Medicine, Health Resources and Services Administration, Indian Health Service, Veterans Affairs, Department of Defense, Appalachian Regional Commission, Federal Communications Commission, and National Rural Electrification Administration. I am proud to say that during my federal career, I was involved in some of these projects as an intramural researcher at the Lister Hill National Center for Biomedical Communications, as a project officer at the National Office for High-Performance Computing and Communications, and as an NIH representative to the Federal Interagency Task Force on Telemedicine. A systematic review of published evidence on telemedicine interventions in primary care found that telemedicine is most effective in improving quality and controlling cost for problems in which patient participation is an important determinant of outcomes.¹ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860623/

Federal regulations requiring in-person visits for many services under their programs have been suspended during the public health emergency.² https://telehealth.hhs.gov/providers/ The most dramatic change in policy is that of the Federal Centers for Medicare & Medicaid Services (CMS) which is now allowing reimbursement to participating providers for most services to their enrollees (in-home, acute care hospitals, and skilled nursing facilities) which previously required in-person contact to be delivered by telehealth.³ https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes Some require live audio and video technology, but many can be done over the voice-only telephone. Many commercial health insurance plans have also dropped requirements for in-person delivery of service. Federal enforcement of the Health Insurance Portability and Accountability Act (HIPAA) requirements for information technology (IT) security in exchange of information between providers and patients has been relaxed to allow for expedient consultation and referral and for providers to use IT convenient to patients for both physical and mental health care.⁴ https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html Federal Drug Enforcement Administration (DEA) is allowing initial evaluation for prescription of opioids like suboxone or buprenorphine for withdrawal and maintenance in opioid use disorder to be done remotely. Prescription of DEA scheduled controlled substances for uses other than substance abuse without an office visit in an established patient is permitted unless prohibited by state law.⁵ https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/dea-information-telemedicine.pdf

Primary care specialty societies are attempting to train their members in the use of telemedicine. The American Academy of Family Physicians (AAFP) has developed a “telehealth toolkit” and has additional links to other organizations’ resources on their website.⁶ https://www.aafp.org/family-physician/patient-care/current-hot-topics/recent-outbreaks/covid-19/covid-19-telehealth.html This toolkit is helpful in determining: which communications tool is necessary for which clinical task; for which patients they might need to be adapted; and determining when in-person visits are necessary. Other primary care medical specialty organizations with resources of either technical or administrative support tools for telemedicine include:

American College of Physicians⁷https://www.acponline.org/practice-resources/business-resources/telehealth
American Academy of Pediatrics⁸
https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/telehealth-care/Pages/default.aspx
The American College of Obstetricians and Gynecologists⁹
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/implementing-telehealth-in-practice

In addition, the following also have resources and guidance on the use of telemedicine by their professionals:

The American Academy of Physicians Assistants¹⁰
https://www.aapa.org/career-central/practice-tools/pas-telemedicine/
The American Association of Nurse Practitioners¹¹
https://www.aanp.org/practice/practice-management/technology/telehealth

Culmore Clinic, where I serve as volunteer medical director, has not resumed office visits since the church which houses us has not yet resumed any onsite group activities. Most of our patients do not have the broadband internet access or technology necessary to do interactive video visits. Counseling services are provided by volunteer licensed professional counselors using only English; language interpreters during in-person visits sat behind the patient (as they did with in-person visits to the medical providers) so that body language contact was maintained between patient and provider. Now, because we are limited to audio, the interpreter must relay information between patients and providers. The effect of triangulation in medical visits is primarily an impairment in efficiency, but the effect in counseling visits is likely more profound and is compounded by the limitation of the counselor to see the physical expression of emotion. Our medical providers are also frustrated by the inability to use the tools of physical examination. Our nursing staff is unable to teach patients the use of insulin pens or syringes, home blood pressure monitors, etc. Because many of our patients are unable to read and are on multiple medications, errors in taking medication as prescribed are more frequent.

Although we have an electronic medical record system with a patient portal, most of our patients can’t use it because of lack of internet access and/or literacy limitations. We text or leave voicemail reminders to patients of scheduled telemedicine visits, but because of the increased demand on our patients’ time with work and child care responsibilities, we have had an increase in missed appointments. Rescheduling these visits requires coordination between providers, interpreters, and staff. Our use of laboratory testing and imaging has increased at least partially as a result of live visit limitations. Because many of our patients share a phone with other household members, we leave messages only if the results of testing are normal; abnormal results necessitate additional telemedicine scheduling. Despite these limitations, we believe that our health outcomes have not suffered; we have actually seen a slight improvement in group mean hemoglobin A1C values in our diabetic patients.

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