The COVID-19 coronavirus is pushing Italy’s health system to its limits, and the United States may be next. There are only so many doctors, rooms, and beds for people who need them. As the cases are increasingly appearing, how can the American health system make sure that people are treated for cases of coronavirus—as well as for more typical diseases—while at the same time limiting new infections? And how can we make sure we’ll have enough resources, knowing that they are finite, for all of our nation’s health care needs? We’re starting to see that a key weapon in the battle against the coronavirus will be telemedicine.
Apparently recognizing this reality, President Donald Trump on Tuesday announced that the Centers for Medicare and Medicaid Services, or CMS, is waiving restrictions on the use of telehealth for the duration of the COVID-19 public health emergency, broadly expanding its use with Medicare paying for virtual visits in addition to in-person visits. Previously, telehealth services were only covered for seniors with established care living in rural areas.
Telemedicine may be one important answer for maximizing resources and supporting the greatest number of people, while embracing the tactic of social distancing. We often think of telemedicine as a means to see doctors from a distance or simply to add convenience. But its particular value in the current situation is how it reallocates in-person care, time, and resources to those who need it most. With telemedicine, we can connect patients with providers using live video—like FaceTime or Skype—or secure text or email systems—like WhatsApp. For every patient that telemedicine triages, avoiding the need for an in-person appointment, another slot is opened up for someone who may have needed it more.
What makes this latest development even more expansive is that CMS also waived enforcement of HIPAA health privacy law violations against providers acting in good faith. This means that everyday communication tools such as FaceTime and Skype, which previously couldn’t be used because they weren’t technically HIPAA-compliant, can now be used for doctors to evaluate patients. It remains to be seen how existing health systems and providers may use these technologies. Privacy remains a paramount concern, and while doctors may not wish patients to be texting them photos and questions on their personal phones, it is now a legitimate option.
Even with the pandemic continuing to advance, most people with mild illnesses and colds do not require the attention of doctors in person, and in fact many cases of COVID-19 can be most safely and appropriately managed outside of traditional health care venues. Thus, telemedicine may prove especially useful in improving access to doctors in areas under quarantine and lockdown.
And yet, while some people may unnecessarily seek the attention of doctors, there are others with problems who aren’t taking them seriously enough. The average person can’t be expected to know what might be a cold and what could be early signs of coronavirus complications, such as respiratory failure. Telemedicine has the potential to both screen populations at risk and expand access to care.
Another way that these moves will ameliorate the burden on the system is in the case of testing. When testing finally becomes readily available—after weeks of rationing that continue to this day—people seeking nonurgent testing may add to systemic strain.
Unique to infectious outbreaks, limiting physical contact with doctors and the health care system may prevent disease spread, while simultaneously ensuring the system won’t get backed up.
How does this all work in practice? At Penn Medicine, Dr. Bill Hanson, an intensive care doctor and the health system’s chief medical information officer, recognized the unique opportunities of this moment. In recent weeks, he has overseen efforts to scale up multiple telemedicine systems: (1) screening patients with automated text messages and calls, (2) virtual visits to triage urgent care and emergency visits, (3) virtual visits to replace outpatient visits for high-risk patients (with poor immune systems, such as chemotherapy patients), and (4) a tele-ICU program to coordinate uniform practices and precautions across many hospitals. Given this rapidly evolving health care crisis, Penn and other hospitals are poised to expand existing telemedicine infrastructure.
Why hasn’t telemedicine been adopted more prior to this crisis? The biggest reason is that most telemedicine practices are not covered by insurance—and in general, doctors and hospitals cannot support practices they don’t get paid for. Last week’s $8.3 billion coronavirus response bill did expand Medicare’s telemedicine coverage, but Tuesday’s news takes that even further. Other barriers that remain include licensing restrictions (e.g., my Pennsylvania medical license does not permit caring for a patient located across a river in New Jersey) and concerns about liability when taking care of people remotely. Though this is a challenging crisis, this may prove a timely opportunity to retrofit our system as we go to fully cover and support telemedicine so that we can be better prepared for surge demand on our limited health resources while also preserving necessary social distancing.
But what if telemedicine care is inferior to in-person care? Doesn’t everyone deserve the gold standard of in-person exams and their personal doctor-patient relationships to determine if they might have coronavirus? It’s true, you can’t listen to someone’s lungs or do a CT scan over a smartphone (yet), and nothing can replace a strong personal relationship. There are limitations to what can be done remotely, but let’s not make false comparisons. Most triage can determine who needs a physical exam in person and who doesn’t. When telemedicine can’t offer that clarity, doctors can still err on the side of caution and refer patients for in-person evaluation. But we simply don’t have the resources to examine everyone all at once. The true comparison is between people not getting any health care to those now getting health care via telemedicine, or between the sick person not getting enough attention because of overburdened doctors and the sick person getting full care.
Beyond mitigating the spread of the coronavirus, we must invest resources now, adapting to the crisis while using it to develop health care for the future. This newest development by Trump and CMS may only be temporary, but it’s a unique opportunity to use telemedicine to its fullest potential, with these barriers currently lifted. With telemedicine, we can expand our system’s triage capabilities to avoid wasted efforts and to handle surges. Most clinical decisions likely can be made by providers not physically present with patients. Once this crisis is over, a revamped telemedicine system would continue to improve access to more people and ensure those who need the most attention can get it.
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