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Until March 2020, telemedicine champion Melissa A. Pynnonen, MD, a professor of otolaryngology at University of Michigan Health in Ann Arbor, had a hard time convincing her department colleagues to use the technology. Some expressed interest; most were reluctant. A few flat-out refused to forego face-to-face encounters.
COVID-19 changed all that.
In February, Michigan Medicine conducted a total of 400 real-time, audio/video visits with the physician and the patient in different locations. That number jumped to 3,000 video visits during the first four weeks of March, and another 3,000 video visits were scheduled for the first week of April alone.
“With the COVID-19 pandemic, providers have been very quick to adopt telehealth and adapt their practices,” said Dr. Pynnonen. “Certainly, in many instances telehealth isn’t a perfect substitution, but during a crisis like this, it’s a wonderful technology that helps us remain connected with our patients.”
As the global pandemic disrupts healthcare services across the globe, a temporary loosening of federal regulations and expanded reimbursement has lifted a number of barriers, encouraging more physicians to try the technology. As of this writing, the Centers for Medicare & Medicaid Services (CMS) allows telehealth visits anywhere in the U.S., with providers and patients able to connect via phone, smartphone, or laptop. Physicians can even use Apple FaceTime, Facebook Messenger, Skype, or Zoom “to provide telehealth without risk that (the Office of Civil Rights) might impose penalties for HIPAA noncompliance,” according to a March 30 memo from the U.S. Department of Health and Human Services. CMS even rolled back rules against practicing across state lines. This means that practices can engage in telemedicine without initially getting involved in a lengthy vendor search, even with electronic medical records (EMR).
“We commend Congress for recognizing the power of telehealth,” Ann Mond Johnson, chief executive officer of the American Telemedicine Association (ATA), said in a March 27 statement. “The telehealth provisions in the CARES Act build on the initial Medicare telehealth waiver authorized by Congress.”
Reimbursement, one of the biggest obstacles to telehealth adoption, according to the ATA, is currently on par with face-to-face encounters—due to the national emergency, CMS is allowing providers to retroactively bill for telehealth visits back to March 6.
Keith A. Sale, MD, associate professor in the department of otolaryngology, head and neck surgery at The University of Kansas Health System (TUKHS), part of the University of Kansas Medical Center (KUMC), agrees that now is the time for otolaryngologists to create or expand their telehealth services.
“The benefit of a crisis is that it creates clarity and opportunity,” said Dr. Sale, who also serves as vice president of ambulatory services at TUKHS. “This is a tremendous opportunity to do things differently and better. I don’t think there’s a specialty out there that couldn’t benefit from telehealth visits.”
Three telemedicine services otolaryngologists can explore:
- Telehealth: real-time, audio/video communication that connects physician and patient in different locations.
- E-visits: synchronous (real-time) or asynchronous (delayed response) virtual visits completed via a patient portal.
- Virtual check-ins: audio-only communications with patients over the phone.
“For otolaryngologists trying to meet patient needs in the short-term, I think FaceTime and Skype are reasonable, given CMS’ relaxation of the HIPAA requirements,” said Dr. Sale, noting that TUKHS accelerated a two-year implementation timeline to just two weeks, and went from 10 weekly telehealth visits to more than 1,000 across 20 departments in one week. “The biggest issue really is speed to market. Our patients want and need telehealth. Our providers are ready and need less than an hour of training.
“We have this golden window now, where some of the rules and regulations around telehealth have been relaxed. This is a great time to experiment and figure out what the next version of healthcare should look like.”
Getting Started
For providers starting from scratch, the American Medical Association (ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice) and the American Association of Family Physicians (aafp.org/patient-care/emergency/2019-coronavirus/telehealth.html) offer comprehensive startup guides and resources. HIPAA-compliant vendors like GoTo Meeting, Updox, and Vsee offer various product levels, demonstrations, and expedited implementation.
We have this golden window now, where some of the rules and regulations around telehealth have been relaxed. This is a great time to experiment and figure out what the next version of healthcare should look like. —Keith A. Sale, MD
Dr. Pynonnen said her department is using the “Lombardy, Italy” model, named after the region in Italy where telemedicine has been used to great effect for a number of digital services for public hospitals, including monitoring patients affected by respiratory insufficiencies and those who are mechanically ventilated. Dr. Pynonnen’s department uses a three-week rotation: Providers are in their offices one week for urgent care and then provide telehealth from home the other two weeks. She added that Michigan Medicine is using its EMR (via laptop or smartphone app), but that some physicians and departments were given permission to use Zoom or other platforms during the crisis. Dr. Sale said that the ideal setup for video telehealth is two devices: one connected to the patient (KUMC uses Zoom for Healthcare) and a second device for the EMR.
“Once somebody shows you how telehealth works, you can very quickly become facile with it,” Dr. Pynnonen said. “It’s helpful to have some formal training or education, even if that’s just a well-written tip or FAQ sheet.”
Although some patients will require an in-person examination, Dr. Pynnonen said telehealth will work well for many situations. “Even in this crisis, we can still help many patients who contact us with symptom concerns by providing reassuring information, despite the inability to look inside their ear or nose,” she said.
Ménière’s disease and vestibular migraine patients who have already had audiograms should be considered for telehealth, said James Lin, MD, associate professor of otolaryngology, head and neck surgery at KUMC. “If they show classic symptoms for Meniere’s, it’s highly unlikely I would see anything different during the physical exam on the day of the office visit,” he said. “Those are perfect patients for telehealth. I can see them, review their audiograms, order an MRI, and start them on Dyazide. I can follow them that way if they’re three or four hours from the office. If they have worsening symptoms, we can telehealth again, or, if it really worsens, we can discuss surgery. We can save a number of in-person visits before it gets to that.”
The AMA recommends using a tele-triage program to ensure that patients seeking appointments are put on the right path through discussing the patient’s condition and symptoms. Some telemedicine services offer this on an after-hours basis, and physicians or staff can be redeployed to manage this during the day. Dr. Pynonnen said administrators and call center staff have been contacting all nonurgent patients based on a priority system TUKHS developed.
Is Telehealth Here to Stay?
With much of the decision about whether or not to telehealth a moot point due to the pandemic, Dr. Pynonnen said the decision-making process is much simpler now. (It’s important to note that the rule relaxation on telehealth may not last, however, so if this is a service you’re considering keeping, you may want to explore more permanent options.)
“A month ago, if we were trying to decide to make a diagnosis about ear pain without an exam, most of us would have said, ‘No, that just doesn’t feel right. I want to look in the ear before I tell them this is TMJ,’” she explained. “Now, a month later, we don’t need a perfect diagnosis. As long as I don’t make a serious misdiagnosis, a best guess with plans for follow-up is good enough in our current crisis.”
Even in this crisis, we can still help many patients who contact us with symptom concerns by providing reassuring information, despite the inability to look inside their ear or nose.” —Melissa A. Pynnonen, MD
“With travel distances to the Oregon border reaching four to five hours for some patients, many have shown such gratitude to have organized video visits,” said Travis T. Tollefson, MD, MPH, professor and director of facial plastic and reconstructive surgery and otolaryngology–head and neck surgery at the University of California, Davis. “Prior to COVID-19, we were encouraged to have 10% of our clinic visits to be video visits through the Epic system’s Haiku or Cantu, but I fought the trend due to a lack of my ability to read the room and interpret the patients’ and families’ demeanor on video.
“This crisis has raised the floodgates on video consults for most of our faculty, and I’m slowly buying into the place for it in my own practice,” he continued. “For follow-ups and screening consults, I think we’ll build on our significant telehealth infrastructure here at UC Davis so that each of us incorporates it. Of course, I’ll be having in-person exams and counselling as we reopen clinics, but I’ve reluctantly given in. Video visits are here to stay.”
Dr. Sale agreed. “The big take-home is to not let perfection get in the way of progress,” he said. “This is more about getting connected to your patients now and being able to share a platform with those who have ongoing healthcare issues—such as sinonasal disease, chronic ear disease, and head and neck cancer—that isn’t just going to go away because of the COVID-19 outbreak.”
Richard Quinn is a freelance writer in New Jersey.
Telehealth Tales
Otolaryngologists from across the country have shared some of their favorite amusing and heartwarming telehealth experiences:
“I was seeing a very sweet lady with benign positional vertigo symptoms. She was sitting on her couch, and I asked if she’d be willing to try the Dix Hallpike diagnostic maneuver to see if her diagnosis was what I suspected—it’s helpful to identify which side is affected for treatment.
“I asked if she had someone at home with her. Her husband was unfortunately out at the grocery store, but she was willing to try it anyway. I had her turn her head 45 degrees and lay back quickly. I couldn’t see her because she had put the phone down, but I heard ‘WHOA!’ and a thump. She had fallen off the couch! I immediately asked if she was okay, and she laughed and said she was.
“After making sure she was okay, she repeated the maneuver on the other side—brave woman! Nothing! So, my diagnosis was confirmed. I sent her a YouTube link so she could do the Epley maneuver at home, with strict instructions to do it only when her husband was with her. She’s doing much better now!”
Cristina Cabrera-Muffly, MD, associate professor, residency program director, department of otolaryngology–head and neck surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo.
“On a recent video visit, one of my patients wrote and performed a telehealth song-o-gram on her experience with recovering from facial reconstruction during the COVID-19 crisis, set to the tune of Bizet’s ‘L’amour est un oiseau rebelle (Habanera)’ from Carmen—it made my day!”
Travis T. Tollefson, MD, MPH, professor, director of facial plastic and reconstructive surgery and otolaryngology–head and neck surgery, University of California, Davis
“Remember that old tale your mom used to tell you: ‘Stop frowning—your face will stay frozen that way’? Well, one of my residents found out that when [you are on] Zoom, your computer can suddenly freeze, creating a prolonged time where your face may be ‘frozen’ in an unfavorable manner. It just goes to show that you should always listen to your mother.”
Tanya K. Meyer, MD, surgeon, University of Washington Medicine Head and Neck Surgery Center; associate professor, head and neck surgery, University of Washington, Seattle
I was at my desk logging in to a telemedicine appointment. (Scene upon connection: Camera view looking at an empty chair at the kitchen table from a device propped up by a bottle of “Off!” insect spray partially blocking the view.)
Me: “Hello?”
Patient from somewhere: “Hello. Can you see me?”
Me: “No, I can see a bottle of Off! and an empty chair.”
Patient: “Oh, I’m on the other side. I can’t figure out how to change the camera.”
Me: “No problem! Can you either turn the phone around or move to the other side?”
Patient: “Good idea. Hold on…” (Ruffling noise and blurry movements on camera)
(New scene: Empty chair on the opposite side of the kitchen table, same bottle of “Off!” The patient has turned the phone around and moved to other side.)
Patient: “How about now?”
Me: “Um, I see an empty chair, I think on the other side of the kitchen table.”
Patient: (realizing the situation) “Oh, right! That wouldn’t work; silly me. (flips phone around) How about now?”
Me: (finally seeing the patient) Never been better! What brings you into the ‘office’ today?”
Michael M. Johns, MD, director, USC Voice Center; division director, laryngology professor, USC Caruso Department of Otolaryngology Head and Neck Surgery, Los Angeles
“I found this comment in one of the daily positivity emails I send to my division: ‘Seeing children smile from their home setting, in their PJs, snuggling with their stuffed animals next to their parents, or running outside, completely unaware of the reality of the COVID-19 pandemic, fills my heart.’ These past few weeks of telehealth have shown me that healing is possible through answering questions and providing information and reassurance.”
Julie Wei, MD, division chief of pediatric otolaryngology, Nemours Children’s Hospital, Orlando