COVID-19

Scope of Telehealth:

• As of March 2020, the Department of Human and Health Services noted that online platforms for telemedicine no longer have to be HIPAA compliant (i.e. FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype)
  • However this does not include public facing/sharing apps (i.e. Facebook Live, TikTok)

Resources for Screening Susceptible COVID-19 Patients: 

• MdCalc has a range of tools providers can use for Telehealth consultations
• Resources specific to COVID-19 include:
  • Apple COVID-19 screening tool is a great resource to direct patients to get testing or not.
  • The Centre of Evidence Based Medicine recommends avoiding the Roth score to assess dyspnea via telehealth. The link to the original paper can be found here.
  • CEBM also offers the following tool to assess for symptoms.

Source: ACEP

Sources:

Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. The BMJ. British Medical Journal Publishing Group; 2020. Available from: https://www.bmj.com/content/368/bmj.m1182

Electronic Medical Record and Codes/Billing: 

• Telemedicine EPIC Template for possible COVID-19 patients, created by Sade Khorami, NP
• Bright.MD COVID-19 Screening Tool: Patient fills in online questionnaire on App -> App uses CDC guidelines and AI automation technology risk-stratify patients -> Patient's personal physician can respond and treat patient all online.
• The American College of Physicians published a resource for Telehealth Coding and Billing Practice Management

Medicare Patients:

• CMS has also temporarily expanded the ability for physicians licensed out-of-state to provide services in a state where they are providing health services.
  • The following is chart of Telehealth billing codes, specifically for Medicare patients (a full list can be found here):

Source: 

CMS List of Telehealth Service

ACEP Guidance of Telehealth

Videoconferencing:

• Access to a medical interpreter is the recommended form of communication between a provider and a patient with limited English proficiency
• Visual communication between the patient, translator and provider through videoconferencing is the closest method to face-to-face interpretation

Family/Friend Interpreters:

• The use of a patient’s family or friends as an interpreter is discouraged due to patient privacy, inconsistent translation quality, and ethical issues—especially in the case of minors

Translation Apps:

• Suitable only in the event that no translator is available
• If needed, language apps allowing two-way communication specifically intended for the healthcare setting are encouraged
• Example of translation apps :
  • Canopy Speak
  • Google Translate
  • Universal Doctor Speak

Sources:

Eysenbach, Gunther, et al. Language Translation Apps in Health Care Settings: Expert Opinion. JMIR mHealth and uHealth. doi: 10.2196/11316.

Masland, Mary C., et al. Use of Communication Technologies to Cost-Effectively Increase the Availability of Interpretation Services in Healthcare Settings. Telemedicine Journal and e-Health: The Official Journal of the American Telemedicine Association. doi: 10.1089/tmj.2009.0186.

Once you’ve established the availability of a virtual consultation, there are a few things one may consider to do ease the transition for your patients:

• Update your website (if applicable)
• Sending an email to patients
• Prioritize what to tell patients including but not limited to:
  • What is Telehealth?
  • How to assure them their personal information is protected
  • What types of care you can offer through health?
  • How this visit may be different from an in-person visit
• Scheduling:
  • How can patients schedule a telehealth appointment?
• Preparing for a visit
  • What videoconferencing tool will patients be using?
  • What they need to do to use the system
  • What to do if they need help troubleshooting
  • Any pre-appointment instructions such as taking their temperature
• MATRC provides comprehensive information for clinicians with setting up and administering health and medicine based services as well as also providing a useful COVID-19 toolkit

Sources:

Mid-Atlantic Telehealth Resource Center: COVID-19 https://www.matrc.org/matrc-telehealth-resources-for-covid-19/

Department of Health and Human Services https://telehealth.hhs.gov/providers/preparing-patients-for-telehealth/

CARES Act

• The Federal Communications Commission (FCC) has allocated $200 million for the COVID-19 Telehealth Program for healthcare providers to expand telemedicine services.
• COVID-19 Telehealth Program funding is limited to nonprofit and public eligible healthcare providers.
• Further information on the impact of the CARES Act on telehealth can be found through the American Telemedicine Association.

Steps Before Applying 

1. Create FCC Registration Number (FRN) through the Commission Registration System (CORES).
2. File FCC Form 460 through the Universal Service Administrative Company (USAC) for eligibility determination from the USAC.
3. Complete registration with the federal System for Award Management.

More information detailing steps for application can be found at the FCC COVID-19 Telehealth Program and further guidance on the application process is provided through the Wireline Competition Bureau. 

Connected Care Pilot Program

• Three-year FCC initiative allocating $100 million for connected care services benefiting low-income or veteran patients.
• This program will fund 85% of qualifying costs acquired from expanding telecommunications, connected devices, and network equipment.
• Funding is preferentially awarded to geographic areas heavily impacted by COVID-19.
• Application information for the Connected Care Pilot Program can be found through the FCC.

Sources:

American Telemedicine Association. FCC COVID-19 telehealth program application guidance [Internet]. American Telemedicine Association. 2020 [cited 8 May 2020]. Available from: https://www.americantelemed.org/policies/fcc-covid-19-telehealth-program-application-guidance/

American Telemedicine Association. FCC COVID-19 telehealth program and connected care pilot program [Internet]. American Telemedicine Association. 2020 [cited 8 May 2020]. Available from: https://www.americantelemed.org/policies/fcc-covid-19-telehealth-program-connected-care-pilot-program/

Federal Communications Commission. COVID-19 telehealth program [Internet]. Federal Communications Commission. 2020 [cited 8 May 2020]. Available from: https://www.fcc.gov/covid-19-telehealth-program

Wireline Competition Bureau. Wireline competition bureau provides guidance on the COVID-19 telehealth program application process [Internet]. Federal Communications Commission. 2020 [cited 9 May 2020]. Available from: https://www.fcc.gov/document/guidance-covid-19-telehealth-program-application-process

Policy Considerations and flexibility of practice during COVID-19

• HHS instituted Notification of Enforcement Discretion to aid health care providers with providing high value care using modern communication applications without violating HIPAA
• Under this guidance, providers may use applications such as
  • Facetime, Zoom, Skype and other video sharing platforms
  • Text based applications such as I-message
  • However, under this notice provider may not use “public facing” platforms such as Facebook Live.
• Those that see further information regarding privacy concerns should keep in mind to be thoughtful and aware of platforms that may break privacy
• CMS (Centers for Medicare &Medicaid Services) have provided the following temporary measures to help facilitate care at this time
  • Providers may use telehealth and conduct appointment with patients wherever the patient is located, even across state lines.
    • However, it is only acceptable to practice across state lines if the states involved have waived and/or reserved practice guidelines
  • Providers may see both new and established patients using telecommunication technology

Sourecs:

Department of Health and Human Services. Policy Changes [cited 8 May 2020]. Available from: https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/

Gadzinski AJ, Gore JL, Ellimoottil C, Odisho AY, Watts KL. Implementing Telemedicine in Response to the COVID-19 Pandemic.