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How COVID-19 Accelerated Telemedicine Use

David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and Healthcare Risk Advisors

Updated May 7, 2020: Telemedicine has been part of the standard delivery of care for years, but barriers to getting started kept many practices from offering telemedicine visits. A confusing patchwork of regulations, lack of electronic healthcare record (EHR) interoperability, and other obstacles found many practices deciding that telemedicine was just more trouble than it was worth.

The COVID-19 pandemic, however, has forced the sudden adoption of telemedicine by many practices and systems, accompanied by government and payer emergency measures that make providing virtual care easier.

While some of these emergency measures will sunset, and while many physicians will welcome the ability to safely see more patients in person, the dramatic increase in telemedicine is here to stay.

Virtual Visits Already Increasing

Telemedicine usage was rising steadily before the advent of COVID-19. The Annals of Internal Medicine published a study of data from a large national insurance company that looked at 142 million primary care visits among 94 million member-years—a massive database covering 2008 to 2016. The authors found a 24 percent drop in primary care visits, but an increase in the number of urgent care and telemedicine visits.

After the pandemic is over, we will see a greater recognition of telemedicine’s role in the movement toward more patient-centered care, more recognition that telemedicine’s risks are manageable and mostly already covered by medical malpractice carriers, and widespread physician education regarding tools for remote examination—just as more business barriers to practicing telemedicine will finally fall.

Patient-Centered Care

Telemedicine skeptics have argued that patients prioritize relationships with their clinicians over transactional care, and that face-to-face visits are better for building relationships. Yet many patients must endure long waits before the first available in-person appointment. (That’s one reason so many patients use urgent care facilities—they can’t get in to see their doctors.) In a patient-centric world, we know that patients want to do what’s easier for them.

Insurance Coverage Is Accessible

Many physicians and most medical malpractice carriers recognize that participation in telemedicine will only increase. Accordingly, physicians have expressed increasing interest in seeing telemedicine covered as a standard part of medical malpractice insurance. The American Medical Association (AMA) recently published a study of physician telemedicine “adoption and attitudinal shifts from 2016 to 2019.” They found that 57 percent of respondents said that telemedicine being “covered by my malpractice insurer” is “very important.”

The market, including traditional medical liability insurers, is receptive to covering telemedicine because it has become a fact of life in the practice of medicine. The Doctors Company has recognized and embraced this evolution in care for many years. Our medical professional liability policy does not draw any distinction between traditional care and telemedicine.

Risks Can Be Mitigated

Fortunately, malpractice risks when providing care by telemedicine remain lower than in most other care situations—perhaps because physicians tend to recognize situations that are not appropriate for treatment via telemedicine. At The Doctors Company, we review our extensive database of claims to identify potential risks so that physicians can concentrate on what they do best—caring for patients—and not on defending their practices. In reviewing our claims, we found that telemedicine-related claims are a very minor part of our overall claims profile. As a component of claims, telemedicine has increased in the past fifteen years (as telemedicine usage has increased), but it’s still very small.

The most common allegation in telemedicine-related claims against our members has been diagnostic error. From these claims, missed cancer diagnoses are most prominent, with stroke and infection running a close second and third.

Allegations of Diagnostic Error in Telemedicine Claims

  • Cancer: 25%
  • Stroke: 20%
  • Infection: 20%
  • Orthopedic concerns: 10%

That the majority of telemedicine-related claims allege diagnostic error shows that while telemedicine is a powerful tool, it does have its limits. The prudent physician knows when a patient’s presenting concern requires an in-person follow-up visit, further testing, or referral to a specialist.

Barriers Will Continue to Fall

Telemedicine skeptics have argued that a virtual visit is not effective. For example, some believe that the physical examination cannot be redefined—as a surgeon, I’ve wondered how you do a good physical exam when a patient isn't in front of you. But as many of us have been learning at high speed during this crisis, for some situations, there are techniques to overcome the obstacle of distance. Medical professional organizations and publications have been distributing educational materials regarding the Ottawa knee and ankle rules for assessing musculoskeletal injuries, the Roth Score for evaluating shortness of breath, and other tools. More information about remote evaluation tools can be found in the NEJM Catalyst article, “The Transition from Reimagining to Recreating Health Care Is Now.”

Even if a patient’s presenting concerns require a hands-on physical exam at some point, telemedicine can be remarkably helpful in learning enough about a patient’s condition to provide triage, a referral to a specialist or physical therapist, patient education on health habits, or otherwise decide how to move forward with a patient’s care. It also gives the physician the opportunity to assure the patient that a live visit, if needed, is worth the extra time, effort, and potential risk.

Physicians should also consider using asynchronous telemedicine as an adjunct. Having patients send data about medication usage, home monitoring of blood pressure, blood glucose, and other parameters can potentially shorten a live visit or preempt it entirely. Post-op care can be dealt with via telemedicine by having patients send drain outputs, pain medication usage, and even photographs of wounds. Using telemedicine in this manner is a good reason to strive to use HIPAA-compliant technology as soon as possible (even though non-HIPAA-compliant technology is currently allowed due to the pandemic).

With telemedicine-appropriate interventions like these, a lot of physicians have already proven the idea wrong that telemedicine is not effective. And the evolution of the regulatory and billing landscapes should make it easier to make a business case for telemedicine as we discover our post-pandemic “new normal.”

Overcoming Business Concerns

Before the COVID-19 pandemic, many would-be telemedicine adopters were frustrated by the maze of often contradictory laws, regulations, and payer limitations they had to navigate in order to provide remote care. These, collectively, contributed to the objection, “There is no business model for telemedicine.” This was never entirely true, but many practices considering telemedicine took a look at the business obstacles and set it aside for the right time. That time is now. The Centers for Medicare and Medicaid Services (CMS), for example, recently addressed some of these business obstacles by announcing it would increase payments for telephone visits with Medicare patients to match payments for similar office and outpatient visits.

This pandemic has shown telemedicine to be far more than an accessory to “regular” care: It is an essential means of care in its own right. Accordingly, federal and state authorities, as well as public and private insurers, have reduced or removed obstacles to telemedicine in order to help physicians manage this emergency—and many of these more telemedicine-friendly regulations are expected to persist.

This does not mean that physicians and practices can ignore expiration dates on certain relaxations of the usual telemedicine rules, or set aside common sense for convenience—those temporarily providing telemedicine by FaceTime will need to transition to a HIPAA-compliant platform. Fortunately, the Federal Communications Commission (FCC) has launched its COVID-19 Telehealth Program, which will provide $200 million in grant funding to help practices start providing telemedicine.

Fewer Barriers, More Learning

As more physicians and practices find that regulatory and payer changes are making telemedicine easier, as these doctors move to learn the telemedicine system perhaps already embedded in their EHR, and acquire facility with the remote-exam techniques appropriate to their specialty, our collective effectiveness at providing care by telemedicine will only increase. Supporting the use of telemedicine has always been important to us at The Doctors Company, but especially during these unprecedented times, we are pleased to be able to provide guidance to physicians as they endeavor to help their patients.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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