key: cord-0048007-nuwf4uk7
authors: Mehrotra, Ateev; Ray, Kristin; Brockmeyer, Diane M.; Barnett, Michael L.; Bender, Jessica Anne
title: Rapidly Converting to “Virtual Practices”: Outpatient Care in the Era of Covid-19
date: 2020-04-01
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0091
sha: 94db9b6a7a80e4c93b6748783e5fbc22c3cf5688
doc_id: 48007
cord_uid: nuwf4uk7

Despite ongoing barriers and limitations, patients find relief with virtual care during the Covid-19 pandemic.

The potential benefits of virtual practices are clear. For patients concerned they have Covid-19, telehealth can address questions, coordinate testing, and triage clinical needs. It can also be used to provide care for individuals in quarantine or recently discharged to home. For patients who have non-Covid-19 issues, telehealth can allow them to receive care without the risk of exposure -a critical concern for older adults and those with chronic conditions. The net effect is reduced exposure to patients and clinicians and a limit on demands of emergency departments. Many of our clinicians are themselves quarantined or must stay at home to care for children; telemedicine has allowed them to continue to provide care.

Before the pandemic, telehealth played a relatively minor role in our practices. All had patient portals with patient-to-clinician messaging capability, but many patients had not signed up. One practice used e-visits,1 a form of asynchronous telemedicine that could be obtained on the portal, and others were using e-consults,2 a mechanism to electronically obtain specialty input clinicianto-clinician, but utilization of these modalities was low. All practices were considering video telemedicine visits, but none had made the leap.

In rapidly adopting telehealth, our goal is to minimize the number of patients who come in. We have dramatically reduced the number of nurses and physicians who physically staff the office, while other staff provide care from their home or "clean" office space. In one of our practices, we have asked only one physician and nurse to come in per day, and we limit in-person care to two visits an hour across the entire practice.

Simultaneously, we are ramping up telehealth modalities, including electronic messaging, within the patient portal, telephone calls, and video visits. To make this transition, physicians are reviewing scheduled appointments and making triage decisions for in-person visits, telehealth visits, or deferred appointments. Our clinics have developed protocols for front-office staff on which visits can be deferred for several months (e.g., annual physicals for adults) or should remain scheduled (e.g., early infancy immunization visits), but most of the triage decisions still require clinician input. Once decisions are made, our offices are calling patients to transition visits where appropriate. An unanticipated complexity is that when physicians call to plan a future virtual visit, this initial call often has turned into an immediate telephone care, resolving the need for a telehealth visit.

We have dramatically reduced the number of nurses and physicians who physically staff the office."

In our new virtual practices, we find that telephone care is the current telehealth mainstay; video visits are taking time to ramp up. In some practices the goal is to make video visits the norm (rather than telephone) to better approximate in-person care and to increase likely payment, while other practices are embracing telephone visits alone. Ongoing barriers to video visits include training clinicians, explaining arrival procedures to patients, using interpreter services, and getting video equipment to clinician's homes. Some attempted video visits unfortunately have had to be switched to the telephone or less HIPAA-compliant platforms such as FaceTime and Skype. While neither of those platforms is compliant with privacy regulations, the U.S. Department of Health & Human Services has recently declared it will not enforce compliance rules in this time of crisis.3

Given varying levels of Internet capacity, some video visits have been plagued by dropped calls, poor image quality, and lags. Clinicians are quickly disseminating best practices for "Web-side" manner, including having the camera at eye level, which clothes work best on a video screen, ensuring our badges are visible to the patient, and removing visual distractions from behind the clinician. 4 We have created macros in our electronic health records to ensure we document patient consent for a telehealth encounter, discuss confidentiality barriers, and document time spent in the visit.

Despite these barriers and limitations, the patient response has almost universally been one of relief." Despite these barriers and limitations, the patient response has almost universally been one of relief. When we connect with patients, we hear they were scared to come into the office and unaware that telehealth was a possibility. Clinicians are also surprised by the scope of care that can be provided remotely through telehealth.

The rules on telehealth payment and regulations are changing by the day. Last week Medicare implemented temporary rules allowing clinicians to bill videoconference visits into any patient's home (or any other site) anywhere in the country. Medicare is also paying for telephone care and e-visits and waiving out-of-pocket costs. Private insurers and some state Medicaid programs are moving in a similar direction. For example, Massachusetts has declared that all telephone and video visits should be covered. However, in other states and with other payers, there remains substantial uncertainty about or limitations to payment. Pediatric practices in particular need state Medicaid programs to rapidly adopt Medicare's evolving positions.

During this crisis, the general attitude among our health systems' leadership is to prioritize caring for our patients, but concerns about practice revenue will escalate as social distancing continues. Our practices are part of large academic systems with financial resources, and we recognize that these concerns are graver still for our colleagues in independent practice and those who work in the safety net.

During this crisis, the general attitude among our health systems' leadership is to prioritize caring for our patients, but concerns about practice revenue will escalate as social distancing continues."

Our newly minted virtual practices are evolving by the day. The goals for the coming weeks are developing better systems for triaging patients to the appropriate level of care, becoming more facile with video visits, and enrolling more patients in our patient portals. Communicating new modes of access to patients is also an urgent need, for which we are using our phone systems, websites, social media, and portal messages. Given the modeling projections on the upcoming wave of Covid-19 cases, we worry that at some point even our virtual health visits will need to be rationed to only those at high risk for illness, and we are already considering protocols on which patients should take priority.

Longer-term strategies we are considering include ensuring that our high-risk patients have technologies at home to track vital signs and other data, and increasing use of e-consults (when available) so that clinicians can virtually incorporate input from specialty colleagues. In the backs of our minds, we worry about the longer-term financial impact of this transition on our practices, how " " we will accommodate the "catch-up" care we are deferring now, and how this transition to virtual care now will change our practices in the long term. For now, however, virtual practice allows us to meet our patients' needs and prepare for the surge of illness to come.

A comparison of care at e-visits and physician office visits for sinusitis and urinary tract infection

Primary care practitioners' perceptions of electronic consult systems: a qualitative analysis

OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. Washington: U.S. Department of Health & Human Services

Training docs on 'webside manner for virtual visits