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Research Cover - June 2020
 
 
 
 
 
 
 
June 2020
Telehealth News:
Research & News Recap

Interest in remote patient monitoring (RPM) and its positive impact has skyrocketed in the wake of the COVID-19 outbreak. Providers across the country are implementing expansive telehealth programs to enhance patient monitoring and disease management while reducing the strain of healthcare resources.

Explore recent research on the efficacy of telehealth in response to the COVID-19 pandemic in HRS’ June 2020 Research & News Recap.
 

Part I. Research Findings - Remote Patient Monitoring and Telehealth

In this section, hear from healthcare organizations across the country who rapidly deployed telehealth programs within the last few months in response to COVID. The articles demonstrate the feasibility of telehealth and remote patient monitoring to combat the COVID outbreak and to extend patient care beyond the COVID pandemic. Additionally, the articles provide best practices for the deployment of telehealth from lessons learned during the COVID-19 pandemic.

Article 1

Cardio-Oncology Care in the Time of COVID-19 and the Role of Telehealth

What was studied?

During the onset of COVID-19, looking at historical outbreaks of infectious diseases, we quickly learned that patients with pre-existing conditions, particularly cardiovascular disease and cancer, had a higher risk for acquiring the virus. Additionally, once infected, these patients were, and are, at a greater risk for the virus resulting in adverse, even dire outcomes.  Reducing exposure among these populations has been and remains critical. Many providers are canceling and rescheduling routine appointments to enforce social distancing and ensure patients avoid the risk of exposure. For patients with a dual-diagnoses of cardio-oncology, cancelling and rescheduling appointments is often not an option.  Routine appointments provide necessary support and care; cancelling them would endanger the patient greatly.

In this article, physicians from the Vanderbilt University Medical Center share how their organization has leveraged telehealth to continue  to provide crucial treatment to cardio-oncology patients and other patient populations in which routine appointments are essential.  In the article the authors discuss the advantages of telehealth for the cardio-oncology population, as well as the clinical challenges they had to quickly overcome  to ensure their telehealth program would be successful. 

Advantages of Telehealth 

  • Virtual visits: Relieving strain on patients and informal caregivers
  • Biometric Devices: Monitoring through biometric devices allows providers to incorporate remote data  to build more comprehensive patient reports and to prevent hospitalizations
  • Patient Education: Allows patients a viable route to learn about their conditions and identify risk factors. For example, educating patients to record their weight and identify signs of edema will improve the quality of the virtual visit with their provider

Overcoming Clinical Challenges

  • Develop Webside Manner: A critical element of virtual visits that revolve around putting patients at ease.
    Helpful tips include: looking directly into the camera, acknowledging the unique setting and reassuring safety and privacy of the encounter, and beginning each visit by taking a moment to thank the patient for inviting you into their home
  • Enhance Coordination with EHR Integration: High-risk patients with multiple conditions as well as providers will require enhanced coordination to ensure essential care is being provided without unnecessary risk. Implementing a telehealth program with your EHR system will reduce inefficiencies while ensuring information from the telehealth platform and all visits (virtual and in-person) is shared across providers.
  • Develop a Visit Schedule: All patients are offered virtual visits within one week of their referral or in place of their original in-person visit. Following their initial virtual visit, a follow-up visit is recommended within one year to evaluate patient status and update their care plan. 

Access the full article, here

Date Published: April 2020

Parikh, Amar, et al. “Cardio-Oncology Care in the Time of COVID-19 and the Role of Telehealth.” JACC: CardioOncology, Journal of the American College of Cardiology, 22 Apr. 2020, www.sciencedirect.com/science/article/pii/S2666087320300685?via%3Dihub.

Article 2

Managing Patients with Chronic Pain During the COVID-19 Outbreak: Considerations for the Rapid Introduction of Remotely Supported (eHealth) Pain Management Services

What was studied?

In the US, more than three million Americans suffer from chronic pain caused by past injuries or surgeries, arthritis, or nerve damage. Not only does chronic pain have a significant impact on a person’s physical health but can also cause contribute to depression and anxiety among other mental health conditions. During the COVID-19 outbreak, remotely treating patients with chronic pain, has become a necessity. Even as elective casework is delayed and primary care providers are required to socially distance, chronic care patients require continued medical support and assistance with their ailments.

Published by the International Association for the Study of Pain, this article proposes guidance for healthcare providers looking to leverage telehealth and virtual care for patients with chronic pain. The authors breakdown the guidance into four categories: public health considerations, delayed care consequences, options for remote patient assessment and management, and clinical evidence supporting remote therapies. In a fifth category, the authors present best practices for healthcare providers attempting to rapidly transition to telehealth and the lessons learned for future application of telehealth and remote care.

Public Health Considerations

  • Populations with a higher prevalence of pain burden are likely to experience higher incidence of COVID-19 infections as the two share many overlapping risk factors including: old age, high population density, smoking prevalence, rate of comorbidities, and lack of access to healthcare
  • Chronic pain management relies first on detection of acute pain. Delayed access to care and diagnostic testing may contribute to a significant increase in chronic pain diagnoses longterm
  • Social isolation in response to COVID may exacerbate depression, anxiety, and loneliness felt by many chronic patient patients

Distance Assessment and Treatment with Technology

  • Clinical assessments can incorporate patient-reported outcome measures.
  • Physical examinations can be undertaken virtually by judging a patient’s appearance and movement.
  • In controlled trials, self-management education and training through virtual visits have proven successful in patient pain reduction.

Evidence for Efficacy and Harm of Telemedicine and DTx Interventions

  • Remote psychological therapies have shown beneficial effects in reducing pain intensity in children and adolescents with chronic pain due to sickle cell disease, musculoskeletal pain, and juvenile idiopathic arthritis
  • In a literature review including studies with over 2000 patients, remote care resulted in small to moderate reductions in pain, disability, and distress
  • Controlled studies have shown benefits comparable with in-person care for physical exercise interventions delivered remotely

Access the full article, here

Date Published: May 2020

Eccleston, Christopher, et al. “Managing Patients with Chronic Pain during the COVID-19 Outbreak: Considerations for the Rapid Introduction of Remotely Supported (EHealth) Pain Management Services.” Pain, Wolters Kluwer, May 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7172975/.

Article 3

Telehealth Transformation: COVID-19 and the Rise of Virtual Care

What was studied?

In this article, published in the Journal of the American Medical Informatics, physicians at the Duke University School of Medicine outline the virtual care platforms incorporated under the umbrella of telehealth. In their outline, the authors include examples of each modality, limitation, and opportunities for expanded use post-coronavirus.

Using examples from US healthcare organizations, including the Duke University School of Medicine, the authors describe the application of telehealth during the COVID pandemic in three phases: stay-at-home outpatient care, initial hospital-surge, and pandemic recovery. Each phase requires coordination between people, telehealth process, and the telehealth technology in order for the health system to successfully deploy and scale telehealth. The authors outline best practices for phases one and two and present considerations for utilizing telehealth post-COVID.

Phase 1: Outpatient care during “stay-at-Home” actions taken:

  • Selecting a Telehealth Platform: Consider virtual patient waiting rooms, privacy and security, and visits scheduling
  • Peripheral Devices: Incorporate biometrics monitoring devices to facilitate remote visits and provide clinicians with more patient data and information
  • Train the Trainer Deployment Model: Create centralized telehealth call-center with telehealth “superusers” to train other providers. Allowed Duke University School of Medicine to train 1300 employees in three weeks
  • EHR Integration: Schedule outpatient virtual visits, share visit notes, and review patient history through the EHR/telehealth integration

Phase 2: Initial inpatient surge

  • Adjust Clinical Workflow: Reassign and train clinicians in less utilized specialty areas to screen, triage, and manage patient responses, identifying less ill patients eligible to recover at home via telehealth monitoring
  • Maximize Staffing Resources: Train staff, including those in quarantine, sharing child care responsibilities, or in high-risk groups, to work remotely
  • Create Tele-ICU: Allow specialists to remotely manage intubated patients
  • Connect Socially Isolated Patients: Leverage telehealth to connect hospital patients, ineligible for discharge, to connect with family and friends

Phase 3: Post-pandemic recovery

  • Prepare for Second Surge: Evaluate areas in which resources were constrained and areas in which the response of the health system was slow or lacking
  • Proactively Address Care Debt: Though ED visits decreased during COVID, necessary treatment and visits for chronic care patients also decreased. Prepare for the influx of patient visits or for the continued transition of in-patient visits to virtual visits
  • Transition to Sustainable Telehealth Platform: Though temporarily accepted during “crisis mode,” stopgap solutions must be phased out for sustainable, decimated telehealth and RPM systems

Access the full article, here.

Date Published: May 2020

Wosik, Jedrek, et al. “Telehealth Transformation: COVID-19 and the Rise of Virtual Care.” OUP Academic, Oxford University Press, 17 May 2020, academic.oup.com/jamia/advance-article/doi/10.1093/jamia/ocaa067/5822868.

Article 4

Telemedicine in the Time of Coronavirus

What was studied?

Countless journal articles have, at this point, been published outlining the use of telehealth to screen patients, monitor recovery and extend care services during the pandemic. However, not many articles have focused specifically on providing telehealth services to palliative patients during or after the COVID outbreak. Prior to the COVID-19 pandemic, the use of rpm and virtual care platforms was growing substantially in hospice and palliative care practices where virtual care saves valuable time for in-home visits and increases capacity at care facilities.

In this article, three physicians from the Division of Palliative Medicine at the University of California, San Francisco (UCSF) provide best practices for implementing telehealth in palliative care. The considerations presented focus on telehealth set-up, patient experience, and clinical effectiveness.  

Best practices & considerations for palliative telehealth

  • For Set up: Identify a “technological liaison” from among the patients family members/caregivers to be a key contact
  • For Set up: Ensure the “technological liaison” is available during virtual visits and send reminder texts, emails, or phone calls
  • For Set up: Provide instructions with your patient portal (if available)
  • For Patients: Set expectations with patients that the clinician may sometimes run late and have a contingency plan if meetings do not start on time. Include this information if patient instructions
  • For Patients: Clearly outline for patients and family members what situations constitute a virtual visit versus a phone call or in-person visit
  • For Patients: Coach patients on telemedicine etiquette; for example, how and when to mute themselves
  • For Providers: Pay close attention to body language and subtle comments made by patient (and caregivers), and ask clarifying questions if you are unable to read their body language
  • For Providers: Orient the patient to where you are taking the call and who else is in the room to reassure the patient that their visit is private
  • For Providers: Use this opportunity to learn more about patients or connect with them. For example, ask them to share some family photos they have nearby

Access the full article, here

Date Published: March 2020

Calton, Brook, et al. “Telemedicine in the Time of Coronavirus.” Journal of Pain and Symptom Management, Elsevier, 31 Mar. 2020, www.sciencedirect.com/science/article/pii/S0885392420301706.

Part II. Reimbursement Updates

Throughout the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) have made changes to their policies in order to make telehealth more accessible across the country. Insights from our reimbursement team are included below.

Reimbursement Updates

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