How clinicians treat patients has been drastically reimagined during the COVID-19 pandemic due to social distancing requirements. Since patients still need to see their doctors one way or another, telemedicine has filled the gap and has been embraced by both the healthcare community and patients alike.
Chirag R. Kapadia, MD, is an endocrinologist at Phoenix Children’s Hospital in Arizona. He reports an encounter patient with a history of thyroid cancer and hypothyroidism. He manages two components of her care: the post-removal of her thyroid, which has done through a combination of physical exam, lab tests, and ultrasounds; and treating her low thyroid, for which Kapadia prescribes a certain dose of levothyroxine.
That dose can change, depending on what a patient’s lab tests reveal, but that change can easily confuse the patients and their families who become unsure of which bottle they’re supposed to pull pills from, or which prescription they’re supposed to refill. “It’s sort of a perpetual problem, because they end up with a lot of bottles lying around,” Kapadia says.
Both Kapadia and his patient suspected she may be on the wrong dose of levothyroxine, but Kapadia was able to employ an elegant solution to confirm this was the case – having been invited to beam into his patient’s home via a telemedicine visit. “I was asking her, ‘How much are you taking of your medicine?’” Kapadia says. “As patients often tell us, ‘The white tablet’ was the respones. They don’t really tell us how much they’re actually on, just a description of what the pill looks like, which is not really always that useful, because different manufacturers’ pills look a little bit different. I said, ‘Why don’t you go get the bottle?’”
When the patient showed Kapadia her prescription bottle, he discovered she was in fact taking and refilling the wrong dose, something he may not have discovered without this virtual house call. “I was able to correct her and get her to pull out her other bottles and say, ‘That’s the one you want to be on and I want you to refill that one every time,’” he says.
Telehealth had already been adopted in spots around the country and was in the works or in its infancy in others, but the COVID-19 pandemic sent the implementation of many telemedicine programs into overdrive. Many institutions have responded swiftly and efficiently. From March 17 to May 31, Phoenix Children’s Hospital’s Endocrinology Department saw 4,400 patients through telemedicine visits – 86% of total visits. In-person visits comprised only 14% of appointments.
Still, these programs are only just emerging, and they’re prone to the tale as old as technology: technical difficulties, legislative hurdles, and good old-fashioned user error. But oddly enough, the COVID-19 pandemic has forced the medical community to innovate in ways that may have taken years to accomplish.
A Semblance of Normalcy
Prior to COVID-19, Carrie M. Burns, MD, associate professor of Clinical Medicine in the Division of Endocrinology, Diabetes, and Metabolism the University of Pennsylvania, says she had not trialed telemedicine, but once the pandemic hit, the transition was quick, and for the past 10 weeks, she has been exclusively utilizing telemedicine for her busy practice.
“I feel fortunate that I have been able to care for my patients safely during a pandemic,” Burns says. “My patients have been grateful as well and have thanked me that we have been able to stay on top of care during such difficult times. It has been a good opportunity to check on them and discuss various matters on how they have been surviving during the pandemic: ideas on how to exercise effectively, check on their mood, safe ways to obtain groceries, etc.”
And in her role as a professor, Burns has been able to continue her commitment to her teaching mission, using video technology for face-to-face meetings with fellows, who have adopted this emerging technology and run with it. “I have been impressed with how easily they were able to transition to a new way of doing things,” she says. “We have managed to complete inpatient diabetes consults remotely – and [the fellows] impressed me at how determined they were to track down the patients and conduct a thorough interview via video.”
“It maintains some normalcy for us all,” Burns continues. “We actually used telehealth for our standardized patient (SP) curriculum this year and the SPs praised our fellows for establishing connections and empathy.”
“I think endocrinology is an ideal field for the e-consult model, just as with telehealth,” Burns says. “It has been satisfying for both patients and our primary care colleagues who are frequently frustrated at our long waits.” – Carrie M. Burns, MD, associate professor of Clinical Medicine in the Division of Endocrinology, Diabetes, and Metabolism the University of Pennsylvania
The University of Pennsylvania responded to the COVID-19 pandemic by developing a “switchboard” through which physicians can see their own schedules at a glance, determine whether patients are in virtual waiting rooms and send them messages when it’s time to join or if the doctor is running late, or contact patients through video, phone, or text.
The Endocrinology Department at Penn stepped up as well, developing a workflow in which patients are contacted ahead of time and asked to download any continuous glucose monitoring or pump data prior to the visit. “Our staff documents the patients’ passwords in a secure location in the EMR, so that we don’t have to search for it each time,” Burns says. “This allows us to quickly have the data at our fingertips at the time of the visits. Moving forward, we are working on developing pathways to decide which patients need to be seen in the office and who should be seen remotely.”
And endocrinologists are especially tuned in to treating patients with COVID-19, as the virus is particularly devastating to patients with comorbidities like diabetes or obesity. Hospitalized patients with the novel coronavirus and diabetes account for more than 20% of the intensive care unit population, according to a study recently published in The Journal of Clinical Endocrinology & Metabolism. But again, telemedicine presents the opportunity to treat these patients as optimally as possible while still mitigating risks.
Burns points out that when she and her colleagues are consulting on patients hospitalized with COVID-19, they were noticing how rapidly these patients’ conditions and treatment plans changed, which meant Burns and her team had to be available at a moment’s notice to give recommendations for rapidly changing scenarios. “In addition, we have to be mindful of our nursing colleagues, who are in the rooms frequently,” she says. “We are sometimes utilizing regular insulin to be able to dose less frequently to help reduce the number of times our dedicated staff have to don and doff PPE.”
Burns says that her practice is slowly transitioning back to a mixture of in-person and telemedicine visits. Still, she doesn’t see a future where healthcare is completely devoid of telemedicine. “I think specifically of my patients I treat for osteoporosis – on a snowy or icy day, I would urge them to cancel – now I would be able to convert these visits to telehealth and still safely deliver the needed care,” she says.
Value Beyond a Pandemic
The very first patient Michelle L. Griffith, MD, associate professor of medicine and medical director of Telehealth Ambulatory Services at Vanderbilt University in Nashville, saw via a telemedicine visit during the COVID-19 pandemic was a gentleman in his 70s with hyperparathyroidism. He initially had trouble launching the video connection, which required help from the tech support line. Griffith says they were eventually able to connect, they reviewed his records, and they had a good, productive discussion.
“I thought he might be annoyed with the technology,” she says. “However, he closed the visit by saying, ‘We should all see our doctors this way, all the time.’”
“Notably, due to Medicare rules, he was only eligible for this service at this time because of the pandemic-related waivers,” Griffith continues. “With just one telehealth experience — despite some technical challenges — he saw the value was not limited to the pandemic.”
And therein lies the hesitance for some institutions to adopt telehealth, and why legislative red tape could still hamstring this technology once the COVID-19 pandemic becomes a distant memory. Burns says that while some at the University of Pennsylvania had been piloting telehealth programs, her department had not been able to incorporate telehealth because of lack of payment for these services.
“From a very practical standpoint, until we have a vaccine for the novel coronavirus, we are likely to continue social distancing measures that are not compatible with full waiting rooms, so telehealth will likely remain an important way to take care of some of our patients.” – Michelle L. Griffith, MD, associate professor of medicine; medical director, Telehealth Ambulatory Services, Vanderbilt University, Nashville, Tenn.
Medicare has relaxed many of its restrictions on payment for telehealth visits, but the administration makes clear that these changes are temporary, so it’s still anyone’s guess how things proceed from here. For the time being, endocrinologists seem have taken advantage of these waivers. “Billing has been one of the easiest parts of using telehealth, as the differences from in-office visits for endocrinologists are minimal,” says Chase D. Hendrickson, MD, MPH, associate professor of medicine and Griffith’s colleague at Vanderbilt. “The problem has always been insurance coverage. The rate and degree of that change over the past several months has been dramatic and allowed us to provide needed care for our patients.”
In order to develop sound telehealth practices at Vanderbilt, Hendrickson says that his department benefited from a close partnership with the Office of Healthcare Compliance, who were able to provide guidance on things like proper coding. “The most important steps were frequent communication on licensing (i.e., which states we can see what types of patients in) and the proper wording to add to our note to indicate that a telehealth visit was conducted appropriately,” he says.
And until things take a dramatic turn, it looks like telemedicine is going to remain the first line of care for endocrine patients; these wrinkles will need to be ironed out, so physicians and patients can feel comfortable sharing the experience of telemedicine. “From a very practical standpoint, until we have a vaccine for the novel coronavirus, we are likely to continue social distancing measures that are not compatible with full waiting rooms, so telehealth will likely remain an important way to take care of some of our patients,” Griffith says.
Still, it turns out that endocrinology is especially well positioned for this brave new world of healthcare, not just for endocrine patients who can be treated just as well from their couches as exam tables, but for the endocrinologist who was just referred a patient.
Referrals for endocrinology are often questions about lab workup or interpretation, according to Varsha Vimalananda, MD, MPH, of the Center for Healthcare Organization and Implementation Research at Edith Nourse Rogers Memorial VAMC in Bedford, Mass and Boston University. Endocrine lab tests often need to be interpreted in the context of other lab tests. “These types of questions are great for e-consults,” she says. “And for e-consults in general, it’s possible one or two lab tests extra might be ordered if you provide recommendations without seeing the patient in person, but if clinical quality is preserved, then on a population level the benefits of not having the patient come in – reduced travel, less care fragmentation, more room in endocrine clinic for more complex patients – may outweigh that cost.”
“Now that patients and clinicians have experienced the convenience and efficiency of telehealth, and payers have established reimbursement to support that, it is going to be very hard to put the genie back in the bottle, and I don’t think anyone will want to.” – Varsha Vimalananda, MD, MPH, of the Center for Healthcare Organization and Implementation Research at Edith Nourse Rogers Memorial VAMC in Bedford, Mass.
Back over at Penn, the Endocrinology Department has emerged as the leader in e-consults, Burns tells Endocrine News. The endocrinologists there have utilized e-consults with their primary care colleagues as a way to differentiate cases in which a simple answer can be given to the primary care provider or whether the patient needs more specialized care. “I think endocrinology is an ideal field for the e-consult model, just as with telehealth,” Burns says. “It has been satisfying for both patients and our primary care colleagues who are frequently frustrated at our long waits.”
Vimalananda says that studies find that specialist recommendations are usually, but not always, carried out, which speaks, which speaks to the primary care provider also having the flexibility to reject the recommendations should they not align with a patient’s priorities and capabilities. “We may also make recommendations that the referring clinician does not feel able to carry out in their clinic either due to their own level of comfort or clinic resources” she says.
And that flexibility is what makes telemedicine so vital to healthcare going forward. “On an individual level, after the technology aspect is sorted out, I think clinicians will really enjoy the opportunity to tailor the mode of healthcare delivery to the case at hand,” Vimalananda says. “In terms of what’s next: ensuring access to the resources needed (for patients and healthcare systems) and developing pathways to determine which patients are most appropriate for face-to-face, telehealth, or e-consult.”
Telemedicine was originally conceived as a way to reach patients who live in remote or distant (from the clinic) locations, or for patients who may have difficulty leaving their houses. Kapadia says that in the past, a patient might have been a no-show because he or she was too busy with work or childcare. But with telemedicine, the patients who previously struggled to keep their appointments have been showing up, connecting to their physicians in previously unprecedented ways.
Phoenix Children’s Hospital also set up a dashboard in which physicians can make determinations whether patients require in-person visits versus telemedicine or simple telephone follow-ups. Physicians are able to look at their future schedules and mark the patients respective to the type of visit needed. However, Kapadia notes that patients can refuse a telemedicine visit and prefer to come in person. “That’s one of the hiccups you can run into because they’re used to coming in, or they may be uncomfortable with the technology,” he says.
And these patients who do live in remote areas may not have the best access to broadband internet, which means a smooth video connection can be next to impossible. “I had a few patients who had to decline telehealth because they knew their internet access was not going to work for it,” Griffith says. “It’s also important to acknowledge that accessing this kind of care at home requires a smartphone, tablet, or computer, and not every patient has those devices.”
Glitches happen, just the same as when Netflix or Twitter is unavailable. Sometimes Wi-Fi drops out or too many attendees on a virtual meeting overload the system. None of these are new phenomena, and telehealth certainly isn’t immune from these high-tech hang-ups. This is still a work in progress, but the benefits definitely outweigh the disadvantages. Everyone here agrees that telehealth has been an effective tool, especially vital during this pandemic where people should remain six feet apart at all times and stay at home whenever possible.
Lockdown orders don’t just interrupt patient care, but physician learning as well, as fellows have seen some disruptions to their curriculums. “A leading priority to bringing patients back into the office includes a plan in which patients can be seen with endocrine fellows to optimize their learning,” Burns says. “However, since telehealth is hopefully here to stay, the fellowship curriculum should incorporate training in best practices for telehealth and this might be offered to our members as well.”
An Emerging and Essential Technology
Telemedicine has provided the opportunity for physicians to do a little medical training with their patients too. Hendrickson has found that his patients have been able to perform physical exams on themselves and transmit the images in real time via their smartphones. “Typically, the camera is of much better quality, and it is far easier for the patients to help examine certain areas (e.g. a visual examination of the feet for patients with diabetes),” he says. “More in-depth patient involvement can be quite challenging, such as asking a patient to palpate their pulse and count it aloud to assess for rate and regularity!”
“Billing has been one of the easiest parts of using telehealth, as the differences from in-office visits for endocrinologists are minimal. The problem has always been insurance coverage. The rate and degree of that change over the past several months has been dramatic and allowed us to provide needed care for our patients.” – Chase D. Hendrickson, MD, MPH, associate professor of medicine, Vanderbilt University, Nashville, Tenn.
Vimalananda says that telemedicine is now tied intrinsically to the future of healthcare, as the COVID-19 pandemic has laid bare just how essential this emerging technology has become. “Now that patients and clinicians have experienced the convenience and efficiency of telehealth, and payers have established reimbursement to support that, it is going to be very hard to put the genie back in the bottle, and I don’t think anyone will want to,” she says.
And while Vimalananda points out that many institutions and patients lack access to the needed technology, many healthcare organizations are rising to the task and addressing the issue.
The Endocrine Society in May hosted a webinar to address the challenges and opportunities presented by telehealth, and ENDO Online 2020 featured an on-demand session devoted to telehealth. “Endocrine Society members should look at their process of conducting telehealth with an eye towards a future where telehealth remains an important part of the care that we deliver and not a temporary mechanism during the pandemic,” Hendrickson says.
“Employers and health plans are also likely to recognize the advantages of more efficient care provided though telehealth and continue to offer it as a benefit,” Griffith says.
And again, patients seem to be warming to these novel ways of visiting their physicians, as the novel coronavirus pandemic continues to loom over the country. “Right now, the majority of the patients are totally amenable,” Kapadia says. “They say, ‘Hey, yeah, that’s great. I don’t have to leave home.’ However, we do now see that gradually, patients are starting to prefer in person again. So I expect the future to be mix of the two.’”
— Bagley is the senior editor of Endocrine News. He wrote about precautions being taken in caring for COVID-19 patients in a hospital setting in the June issue.