key: cord-0854242-8w03car3
authors: Hare, Nathan; Bansal, Priya; Bajowala, Sakina S.; Abramson, Stuart L.; Chervinskiy, Sheva; Corriel, Robert; Hauswirth, David W.; Kakumanu, Sujani; Mehta, Reena; Rashid, Quratulain; Rupp, Michael R.; Shih, Jennifer; Mosnaim, Giselle S.
title: COVID-19: Unmasking Telemedicine.
date: 2020-06-27
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2020.06.038
sha: c8a5784a253f29866595f3b17254b1b334acecfc
doc_id: 854242
cord_uid: 8w03car3

Abstract Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic.1 Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing in order to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020 to detail Pre-COVID-19 telemedicine knowledge and outline up to date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape.

The COVID-19 pandemic led to an unprecedented change in clinical operations, motivating 91 physicians and healthcare systems worldwide to rapidly implement telemedicine programs to 92 reduce or replace in-person visits. 1 Telemedicine has allowed for increased workforce 93 sustainability, limitation of clinician direct exposure to patients, overall reduction of personal 94 protective equipment (PPE) use, and may reduce clinician burnout. It has also facilitated staffing 95 of both large and small facilities that are overwhelmed with pandemic-related patient overload. 2 96 In addition, telemedicine has been used for surge control or "forward triage" -the triaging of 97 patients before they arrive in the emergency department (ED). Direct-to-consumer (DTC) visits 98 have allowed patients to be efficiently screened while protecting patients, clinicians, and the 99 community from exposure. 3 100

This rapid need for telemedicine visits has generated the demand to effectively educate 101 allergists/immunologists on how to optimize utilization. Prior to the pandemic, telemedicine was 102 often reserved for patients with decreased access to care. It is quickly becoming the preferred 103 mode of delivering care for both follow-up and new clinic patients. 3, 4 Recognizing telemedicine 104 as a growing field for the practicing allergist/immunologist, the American Academy of Allergy, 105

Asthma and Immunology (AAAAI) Health Informatics, Technology and Education (HITE) 106

Committee established a Telemedicine Work Group (TWG) to review multiple aspects of 107 telemedicine including utility, adoption procedures, billing, security, electronic medical record 108 (EMR) integration, education, and state specific issues. 109 110 Traditional Rationale for Telemedicine: Convenience of Care, Increased Access, and Cost 111

Telemedicine has been shown to decrease costs of travel for patients in both time and money. 113

By making it more convenient for them to obtain care, telemedicine has increased access for 114 patients who might not otherwise be able to receive care or be seen at a given practice. 5, 6 115 Prior to the COVID-19 pandemic, patients who may have benefited from telemedicine included 116 poor, elderly or disabled patients, or those who simply lived too far away to travel for an in-117 person visit. 5 Telemedicine is well-suited to large rural states or medically underserved urban 118 areas. A 2019 study found that telemedicine in the Veteran's Health Administration (VHA) has 119 likely improved access to care for veterans who live in rural areas. 7 120

This convenience is also applicable in emergency and hospital settings where specialists may 121 not be on site. Virtual consultations can limit the need for transportation of ED patients to other 122 facilities for care and hospital transfers. 8, 9 As early as 2007, estimates predicted that 123 teleconsultations could obviate the need for up to 850,000 transfers and save US$537 million 124

dollars per year. 8 125 A 2016 retrospective study done in the VHA looking at data from 1997-2008 found that, for the 126 clinics studied, the mean no-show rate for doctor appointments was 18.8%. The average cost 127 of a no-show visit in the VHA in 2008 was US$196. 10 Telemedicine may help improve patient 128 compliance and decrease the associated financial cost to practices and clinicians of no-show 129 visits by reducing barriers to care. 11 Cost-benefit analysis data for the use of telemedicine is 130 minimal at this time. However, recent studies conducted in tele-dermatology and telemedicine 131 in the pre-hospital care setting have recently shown promising results. 12, 13 132 133

Despite the exponential growth of telemedicine in the past five years in the United States, the 135 adoption of these services by the allergist/immunologist community was minimal prior to the 136 pandemic . 14 Several factors contribute to the rationale for growth of telemedicine during the 137 COVID-19 pandemic. First, the public health emergency (PHE) has led to the development of 138 guidelines for quarantine as well as for social and physical distancing . 15 Steps Involved in Starting a Telemedicine Program 154

The first step in setting up a telemedicine program is determining the types of patients that will 155 be seen. Assuming that federal, state, malpractice, and insurance guidelines are taken into 156 account, these may include initial consultations, established visits, and patients at a distance. It 157 is important to know the limitations of telemedicine, as there are certain visits that can be 158 challenging to perform through telemedicine. Procedures and procedure-related visits, such as 159 allergy skin tests, immunotherapy and/or biologic injections, food and/or drug challenges, in 160 general are difficult to accomplish except in the case of a facilitated visit where a trained 161 clinician is present at the patient's site who is adequately trained and is able to accept 162 responsibility for treating the patient if a systemic allergic reaction occurs. 163

The next step is to decide whether the telemedicine visits will be through a synchronous or 164 asynchronous approach. Asynchronous telemedicine is communication with a patient separated 165 by distance and time. Synchronous telemedicine is where the clinician and patient are 166 connected at the same time in a live interactive audiovisual exchange. 167

Synchronous telemedicine is further classified into direct-to-consumer (DTC) visits or facilitated 168 visits (FV). A direct-to-consumer (DTC) visit occurs between the patient and clinician at a non-169 medical facility, such as the home, where communication is directly through the patient's 170 smartphone or computer. A facilitated visit (FV) requires a facilitator to operate equipment and 171 guide the patient through the video visit. 172

The equipment needed at the origination (patient) site depends on whether the appointment is a 173 facilitated visit (FV), a DTC visit, or a telephone visit. Please refer to the online supplement for 174 Specific Technology Guidelines. For a FV, there should be a specific room in which the patient 175 can be seen (often a regular examination room). Most origination sites have a "telemedicine 176 cart", which contains the hardware, software and other equipment needed for a telemedicine 177 with the patient, establishing their role and connection with the patient is recommended. 196

Once the platform and equipment are in place, the next step is to organize the scheduling of 197 patients. Guidelines for patients best suited for telemedicine should be established. Pre-clinic 198 huddles can be effective forums for identifying patients suitable for telemedicine visits. Initially, 199 consider scheduling the same amount of time for a telemedicine visit as an in-person visit to 200 allow a buffer for technology issues that may come up. Documentation in the EMR can be done 201 at the same time as talking to the patient. The scheduling of telemedicine visits among in-202 person visits depends on practice efficiency, notification system, and workflow. This can be 203 adjusted as needed. 204

One important aspect to developing a successful telemedicine program is adequate training. software. If that fails, one may have a backup, encrypted independent platform. If the first two 211 encrypted options fail, traditional phone modalities may be used (See Tables IA and IB for  212 examples of encrypted and non-encrypted telemedicine platforms, respectively). Flexibility and 213 versatility in dealing with technology failures in real time is paramount. 214

Providing checklists or a toolkit for patients that include educational handouts on the patient's 215 expectations, an introduction to the consent process, how to contact information technology if 216 they encounter difficulties during the visit, and how the patient can prepare to ensure a stable 217 digital connection during the visit is essential. Online tools including podcasts and webinars can 218 offer clinicians multiple medical education modalities. 11 Please see Table II (Online Resources  219 for Telemedicine). 220

Clinic schedulers and other staff should contact patients prior to the visit to discuss preparation 221 for their telemedicine visit. Included in this discussion should be a review of the devices 222 (computer with camera, smartphone, phones, digital tablets) that can be used for the remote 223 telemedicine encounter. In addition, test calls with the device are recommended to ensure the 224 patient will be able to reliably connect to the clinician for their telemedicine visit. Depending on 225 the platform and the healthcare system involved, consent, required by most states, may be 226 obtained by the clinic staff or clinician and documented prior to the visit. Even if obtaining a 227 patient consent for telemedicine visits is not required in a particular state, it is an advisable best 228 practice to implement in telemedicine. 19 229 A telemedicine visit starts when the patient logs into the telemedicine site. Some EMRs have an 230 integrated telemedicine application, thereby eliminating the need for a separate telemedicine 231 application. However, this is not a requirement; the telemedicine and EMR applications do not 232 have to be linked. Once a connection with the patient has been established and consent 233 obtained, the encounter can start. It may be helpful to have the patient's chart in the EMR open, 234

either on the same screen or on a separate screen, to refer to and facilitate documentation 235 during the visit. The clinician may want to discuss what to do if the call drops or internet access 236 is disrupted with the patient at the start. Documenting information from the patient as to their 237 current location and phone number is recommended as it can be used to contact emergency 238 medical services (EMS) services if an emergency occurs during the telemedicine visit or if the 239 connection with the patient is lost. 240

The clinician should then conduct the history as they would for an in-person visit. After the 241 history has been obtained, a physical examination is performed. The depth of the physical exam 242 depends on the location of the patient. If the patient is at a medical facility, the physical 243 examination can be performed with the use of peripheral equipment (e.g. electronic stethoscope 244 and otoscope) and the facilitator. If it is a DTC visit, a physical exam can still be performed, with 245 the clinician guiding the patient to maneuver certain aspects for visualization. As expected, the 246 telemedicine exam is not as comprehensive as compared to an in-person exam. However, it is 247 not as limited as one might expect. With a little creativity, the clinician can still obtain a fair 248 amount of useful data from the telemedicine exam. (See Table III for example telemedicine 249 physical exam pearls). After the physical exam and medical decision making, an assessment 250 and plan are formulated. It is necessary to write orders, give prescriptions, and provide 251 instructions to the patient to conclude the visit. Please see Table IV for an overview of the Steps 252

for Conducting a Telemedicine Visit. 253 254

The utility of EMR integration can depend upon the type of telemedicine that is employed. For 256 remote monitoring telemedicine, there have been studies using patient-facing technologies to 257 collect patient-generated health data that then flow into EMRs (such as peak flow or frequency 258 of MDI use). 20, 21 However, these processes currently remain cumbersome and are not widely 259

implemented. For video conferencing telemedicine visits, the medical history, orders, and visit 260 notes associated with each video visit are integrated within the electronic health record (EMR), 261 thus improving work flows and clinician/patient satisfaction. 22, 23 The patient-facing interface can 262 be via the vendor's mobile application or EMR patient portal. EMR telemedicine vendors offer 263 additional features including integration with referral management, scheduling and visit 264 reminders, patient intake, and patient communications. Please refer to the E-supplement for 265 additional information on Integration with EMRs. 266 267

In a recent meta-analysis, combined tele-case management and teleconsultation were effective 269 telemedicine interventions to improve asthma control and quality of life in adults. 24 Telemedicine 270 was also used to provide asthma education in medically underserved areas. Scheduled 271 facilitated telemedicine visits with certified asthma educators over a period of one year reduced 272 the number of unscheduled visits for asthma. 25 In addition, telemedicine was shown to be non-273

inferior to in-person evaluation for asthma care. This is particularly important in medically 274 underserved areas where access to asthma specialists may not be readily available. Remote 275

Presence Solution (RPS) equipped with a digital stethoscope, otoscope, and high-resolution 276 camera was used to perform the visits in this study, with either a registered nurse or respiratory 277 therapist serving as telefacilitator. 26 A pilot study of 50 patients published in 2018 utilizing 278 telemedicine to evaluate penicillin allergy demonstrated high patient satisfaction and potential 279 savings of over US$30,000 dollars due to increased access to specialty allergy/immunology 280 care and improved antibiotic stewardship. 27 As with any benefit comes an evaluation of risk. 281

Patient safety and the lack of inferiority of the quality of care with telemedicine versus standard 282 care are ongoing areas of research. 28 283

The relationship between telemedicine reimbursement rules and access to care is complex. 285

Concerns about potential overuse and quality of care have caused many payers to place 286 considerable restrictions on fee-for-service telemedicine coverage. Inconsistency among payers 287 and states in coverage for telemedicine services may shift costs from payers to clinicians and 288 patients, preventing adoption. The opportunity cost of non-reimbursed or under-reimbursed care 289 has been a major barrier to telemedicine implementation and prior to COVID-19 prevented 290 many physicians and health systems from offering potentially valuable telemedicine services to 291 their patients. Studies show that when reimbursement is limited, patients are under-served by 292 telemedicine services. 29 293

Coverage 294

Although parity in coverage (both in-person and telemedicine services are covered for the same 295 indication) and payment (e.g., meaning that reimbursement for telemedicine services 296 approximates that of the equivalent in-person E/M service) has never been universally 297 mandated, payment parity is the coveted norm. Existing data suggest that enactment of parity 298 increases adoption of telemedicine. Almost 90% of both users and non-users (of telemedicine) 299 said they would use telemedicine if they were to be reimbursed. 29 In fact, a 77.5% increase in 300 telemedicine adoption was noted after implementation of parity in Michigan. 30 301

Because telemedicine coverage and reimbursement are not federally regulated, there is 302 considerable variability in rules, depending on the state and insurer. No two payers or states are 303 alike in how they define or cover telemedicine services. Although the COVID-19 PHE has 304 certainly brought increased coverage for telemedicine services, nationwide standardization of 305 coverage and payment policies is still lacking. The Center for Medicare and Medicaid Services 306

(CMS) has historically placed strict limits on criteria for telemedicine reimbursement, requiring 307 patients receiving telemedicine services to reside in a rural area and travel to a designated 308 health center to receive facilitated care via a synchronous live video link. 31 However, these strict 309 limits on telemedicine services may have contributed to thwarting innovation and adoption of 310 new technologies, thereby limiting access to care. Even before the COVID-19 pandemic, CMS 311 had pivoted to enhanced coverage of telemedicine. 312

Medicaid has generally had broader telemedicine coverage than Medicare, but rules vary from 313 state to state. Currently, all 50 states and Washington DC provide reimbursement for some form 314 of live video in Medicaid fee-for-service plans. Fourteen states reimburse for store and forward 315 delivered services (not including teleradiology). Twenty-two states reimburse for remote patient 316 monitoring (RPM). 32 317

insurer-specific policies. Currently, 40 states and Washington DC have laws that govern private 319 payer telemedicine reimbursement policies. 33 Some laws require reimbursement be equal to in-320 person coverage. However, most only require parity in covered services, not reimbursement 321 amount. Depending on how the law is written, it may provide payers with the ability to limit the 322 amount of that coverage. Unfortunately, inconsistent coverage and reimbursement policies 323 among the various insurers can lead to confusion, incorrect coding and billing, and denied 324 claims. 34 325 Some patients prefer to pay a convenience fee to access non-covered telemedicine services 326 rather than come into the office for an in-person visit or forgo care. Costs vary significantly but 327 tend to be lower than the routine charges for an in-person evaluation. 35 328

Correct coding of telemedicine services is essential to obtaining reimbursement for care. In 330 most cases, coding for telemedicine services was done using the corresponding codes for an in-331 person E/M visit (using either time or history and medical decision-making to justify the level), 332 but with commercial insurers requiring the -95 modifier (synchronous telemedicine service 333 rendered via a real-time interactive audio and video telecommunications system) appended. 334

Some insurers also accepted modifier GT in lieu of 95. Medicare did not require a modifier for 335 E/M services provided via telemedicine. Place of service was to be designated as "02" to signify 336 telemedicine for all payers. While Medicare only covered telemedicine services for established 337 patients, some private payers permitted telemedicine visits for new patients, but not with the 338 standard new patient CPT codes. Instead, they required billing with code 99499 (Unlisted 339 evaluation and management code) with place of service "02". This may have been associated 340 with lower reimbursement than an in-person new patient visit. Due to this variability, it had 341 always been best to check with each individual payer to determine how best to code 342 telemedicine visits. For further information about CMS coverage of telemedicine services pre-343 COVID-19, see Table V . Table VI for coding and billing 353 telemedicine visits by time. For visits that are based on exam, documentation requirements for 354 the systems that were examined is the same as for an in-person visit. Please see Table III for 355 telemedicine physical exam coding guidance. 356

The COVID-19 PHE has rapidly ushered in expanded coverage/reimbursement for telemedicine 358 services by both CMS and commercial payers. 18 One of the major changes from Medicare 359 includes the lifting of geographic restrictions on patient location, making telemedicine services 360 available to Medicare beneficiaries residing outside of underserved rural areas. Beginning 361 March 6, 2020, Medicare permitted patients to receive telemedicine services regardless of 362 location and without the need to leave their homes to visit an originating site, such as a clinic 363 that might be used for a FV. This means that, for the first time, Medicare patients can receive 364 telemedicine services from the comfort and safety of their own homes. CMS issued guidance to 365 use modifier -95 to designate an E/M service as telemedicine, and change the place of service 366 for all care to the location in which the service would have ordinarily been provided instead of 367 "02", thus enabling payments to achieve parity with in-person rates instead of being reimbursed 368 at the lower facility rates. Although CMS itself is not waiving the cost-sharing for beneficiaries 369 during the COVID-19 PHE, the Office of the Inspector General (OIG) policy statement informed 370 practitioners that they will not be sanctioned for choosing to reduce or waive a patient's cost-371 share obligations. 36 During the COVID-19 pandemic, Medicare has continued to allow 372 telemedicine visits to be billed either by E/M (with history, physical exam, and medical decision 373 making, as per a normal in-person office visit) or by time (If billing based on time, 50% of the 374 time must be spent on counseling and/or coordination of care, as per a normal in-person office 375 visit). Please see Table III for telemedicine physical exam coding guidance and Table VI for 376 coding and billing telemedicine visits by time. Finally, Medicare temporarily has permitted new 377 patient codes to be billed for telemedicine visits and allowed telephone visits to be reimbursed 378 at face-to-face rates, enabling virtual care for those patients without access to video technology. 379

After weeks of rapidly changing guidance from commercial payers, many have now followed 380 CMS's lead, and adopted many of the same telemedicine coverage expansions. This has 381 interestingly resulted in telemedicine billing/coding guidance that is significantly more uniform 382 than pre-COVID-19. Many commercial payers are now covering new patient visits via 383 telemedicine. Additionally, many have issued guidance to bill using the place of service "11" 384 instead of "02", along with modifier -95 or -GT. In many (but not all) cases, this will result in 385 payments that achieve parity with in-person rates. See Table VII for Pre-and During-COVID-19 386 changes based upon insurance. Some states without coverage and payment parity laws have 387 issued executive orders temporarily mandating coverage (and in some cases, payment) parity 388 for telemedicine services provided for state residents. 37 It remains to be seen if the increased 389 adoption of telemedicine resulting from these changes will be maintained post-COVID-19 or if 390 coverage and parity policies return to baseline. See Table VIII for examples of telemedicine 391 coding and billing. 392

Past data has shown that health care systems average a time period of 23 months to implement 394 digital healthcare solutions. 38 With the mounting pressure to preserve clinical operations 395 remotely during the COVID-19 pandemic, many health care systems were faced with 396 implementing telemedicine within a few weeks. Systems that had already identified superusers 397 and who had utilized telemedicine to address medical care access issues were quick to expand 398 their telemedicine services. For any health care system, key factors of successful 399 implementation include stakeholder engagement, end user buy-in, effective educational delivery 400 programs and soliciting feedback. 38 Preparing clinicians for implementing telemedicine involves 401 understanding of how telemedicine affects various aspects of the traditional clinic workflow, 402 which will look different for a large health care system vs academic setting vs 403 allergy/immunology private practice. 39 (See Table V) . 404

In addition to these components of education, clinicians will require access to information 405 regarding the most suitable telemedicine platform for their current needs. They expect to be 406 able to access this information quickly as it rapidly changes during and after the post COVID-19 407

pandemic. Platforms will differ on the breadth of data security and privacy that is offered and will 408 vary in their ability to be integrated within the EMR available to the clinician for documentation 409 and billing. 410

Federal regulators announced another set of regulatory changes and waivers, particularly 412 relating to telemedicine, in response to the growing pandemic crisis throughout the United 413

States. These changes are described in the E-Supplement. with, specific technology requirements, and payer specific requirements as well. This process 441 has been accelerated with the COVID-19 pandemic, and many regulatory and payer issues 442 have been waived or modified to allow a rapid response to changing practice logistics, such as 443 eliminating licensing requirements for out of state telemedicine visits until the COVID-19 444 pandemic emergency has diminished. 445

Upon the rescinding of federal and state emergency orders related to COVID-19, these 446 requirements may revert back to their prior complexity or continue to exist in a partially modified 447 form. It is therefore advisable that all of these bodies be consulted prior to beginning/continuing 448 the practice of telemedicine in order to ensure proper care, fair reimbursement, avoidance of 449 unforeseen medicolegal issues, and to provide the best care for our patients. It is also advisable 450 that clinicians regularly check laws, legislative agendas, best practice recommendations, and 451 payer policies to ensure the practice continues to be compliant. This section will provide 452 information for approaching this process and cover regulatory issues at the state level, but not 453 reimbursement or technology requirements. 454

Efforts are being made by the Interstate Medical Licensure Compact Commission, 44 (a branch 455 of the Federation of State Medical Boards that joins 29 states, the District of Columbia and the 456 Territory of Guam), to continue expansion to other states as they assist physicians with their 457 telemedicine licensing needs.This is an excellent resource for ongoing formation regarding 458 licensure. Upon expiration of current emergency orders removing barriers to telemedicine 459 licensure and requirements, the lack of license portability will continue to be a barrier. There is 460 an expedited process for licensing board-certified physicians with no background issues. But 461 physicians practicing in multiple states must adhere to a variety of state-specific medical 462 practice regulations, and there are annual license renewal fees for each state license. There is 463 no national licensure at present. The exception to this is patients and clinicians working with the 464 Veterans Administration (VA) system, where rules were in place effectively bypassing state 465 licensure laws. 45 Please see the specific licensing issues in the E-supplement. 466

It is important to maintain Health Insurance Portability and Accountability Act of 1996 (HIPAA) 468 compliance in a telemedicine visit in the same manner as an in-person clinic visit. 469

Medical professionals often mistakenly believe that communicating electronic protected health 471 information (ePHI) is acceptable when the communication is directly between physician and 472 patient. Often, little regard is given to the method of communication that is used for 473 communicating ePHI. Medical professionals who wish to comply with the HIPAA guidelines on 474 telemedicine must adhere to rigorous standards for such communications to be deemed 475 compliant. HIPAA requires ePHI data be encrypted when they are transferred. 5 HIPAA also 476 directs that a telemedicine vendor must monitor data that are stored during transfer. Skype do not have a BAA and thus previously did not fully comply with HIPAA. Some small 491 practices use these platforms for telemedicine. However, some insurers will not pay for 492 telemedicine care that uses the non-BAA platforms, and some large organizations will not allow 493 their doctors to use these platforms. 49 In addition, copies of communications sent by SMS, 494

Skype, or email remain on the service clinicians´ servers and contain individually identifiable 495 healthcare information that is not encrypted. This ePHI is also not considered HIPAA 496 compliant. 50 497

There are a variety of vendors that provide telemedicine technology (Table IA) . Because each 499 technology changes frequently, it is important to visit each vendor's website for information 500 about current offerings. It is important to check with each company to determine HIPAA 501 compliance and encryption and to verify it with an IT security expert. 51 Other technologies to 502 consider utilizing include Intrusion detection systems (IDS), web application protection, and log 503 management. 504

Patients have every right to be concerned about privacy and question how their information will 506 be handled during a telemedicine visit. Clinicians should be prepared to educate patients about 507 the steps taken for HIPAA compliance and ways to ensure the privacy of other confidential 508 information. It is important to let patients know technology is designed for this purpose and that 509 clinicians take this obligation under HIPAA very seriously. 4 510

The emergency declaration by the President of the United States on March 15, 2020 removed 512 some of the HIPAA and state-related barriers that required recording all telemedicine visits and 513 that those copies be maintained in an archive as part of the medical record. For the time being, 514 CMS has also noted that accidental HIPAA violations that occur in the course of caring for 515 patients via this method will not be prosecuted, as long as the clinician was acting in the best 516 interest of the patient. Many state governors have released similar letters providing similar 517 policies for Medicaid in their respective states. With the declaration, the originating site can be 518 the patient's home, nursing homes, hospital outpatient departments, and other settings and 519 across state lines. 11 520

To immediately allow clinicians to start telemedicine services, HHS Office for Civil Rights (OCR) 521 will exercise enforcement discretion and waive penalties for HIPAA violations against healthcare 522 clinicians who serve patients in good faith through everyday communications technologies such 523

Zoom (Zoom Video Communications, Inc., San Jose, CA), Skype, and FaceTime, among 524 others. 52 Telemedicine visits are also more flexible in that the video solution has an exception 525 for HIPAA security rules requiring BAA for technology. This change now also supports platforms 526 such as Facetime, Google Hangouts, and Skype which do not offer a BAA. Nevertheless, best 527 practice is to work toward the use of a HIPAA-compliant video solution as soon as available. 528

This emergency declaration regarding telemedicine requirements is to extend through the 529 COVID-19 PHE. At this point it remains unclear how long these changes will remain in effect or 530 what form they will take once the COVID-19 emergency ends. To dispel any confusion, 531 clinicians need to remember that HIPAA regulations are still in place at this time; it is the 532 enforcement of these regulations that has been temporarily relaxed. 533

Telemedicine has been shown to increase access to and decrease the cost of medical care. 5, 8, 535 10, 47, 53 Many of the types of patients that we care for in the field of Allergy and Immunology can 536 be helped using telemedicine. Past examples include the use of telemedicine for asthma and 537 antibiotic allergy and stewardship. [24] [25] [26] [27] We and our patients are therefore uniquely positioned to 538 take advantage of and benefit from telemedicine. 539 540 Until recently, however, there was not widespread adoption of telemedicine. Therefore, a work 541 group from the Health, Information, Technology and Education (HITE) Committee of the 542 American Academy of Allergy, Asthma, and Immunology was formed to investigate the 543 baseline use and needs of the allergy and immunology community with regards to 544 telemedicine. Since that time, the COVID-19 pandemic has led to an unprecedented 545 heightened need for telemedicine from private practices to academic centers throughout the 546 country. 2, 3, 54 There is now an opportunity to integrate telemedicine into the Medical Education 547 curriculum and experience telemedicine at all levels. It remains to be seen if the changes in 548 technology, regulation and reimbursement of telemedicine will be maintained long term. 549 550 HITE is planning to longitudinally follow the adoption of telemedicine by allergy/immunology 551 clinicians in the context of COVID-19 and afterwards. Our goal is to continue the development 552 of tools to assist allergy/immunology clinicians with adoption of telemedicine and to help push 553 the boundaries of telemedicine use by the allergy and immunology community. 

COVID-19: 557 Pandemic Contingency Planning for the Allergy and Immunology Clinic

Keep Calm and Log On: Telemedicine for 560 COVID-19 Pandemic Response

Virtually Perfect? Telemedicine for Covid-19

Department of Health & Human Services. Health Information Privacy

Tips for Seeing Patients via Telemedicine

Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants. 569 Value in Health

Utilization of Interactive 571

Clinical Video Telemedicine by Rural and Urban Veterans in the Veterans Health Administration Health 572 Care System

American Telemedicine Association. Examples of Research Outcomes: Telemedicine's Impact on 574

Adding telemedicine to ICUs in VA hospitals reduced transfers of sickest 579 patients

Prevalence, predictors and 582 economic consequences of no-shows

Telemedicine in the Era of COVID-19

586 A cost savings analysis of asynchronous teledermatology compared to face-to-face dermatology in 587 Catalonia

Cost-589 benefit analysis of telehealth in pre-hospital care

Centers for Disease Control and Prevention, Department of Health and Human Services

Office of Inspector General. Hospital Experiences 600 Responding to the COVID-19 Pandemic: Results of a National Pulse Survey

medicare-telemedicine-health-care-provider-fact-sheet. 605 19. The Center for Connected Health Policy. National Policy: Informed Consent

Effectiveness of Population Health Management Using the 608

Propeller Health Asthma Platform: A Randomized Clinical Trial

An Internet-based store-and-forward 611 video home telehealth system for improving asthma outcomes in children

Telemedicine Integrated With Clinical Care: Patient Experiences

Telemedicine Integrated with Clinical Care

The 618 Effects of Telemedicine on Asthma Control and Patients' Quality of Life in Adults: A Systematic Review 619 and Meta-analysis

The uses of telemedicine to improve asthma control

Telemedicine is as effective as in-person visits for 623 patients with asthma

The Use of Telemedicine for Penicillin Allergy Skin 625 Testing

Patient safety risks associated with telecare: a systematic review 627 and narrative synthesis of the literature

Lack of Reimbursement Barrier to Telehealth Adoption

State Policies Influence Medicare Telemedicine Utilization. Telemed 632 J E Health

The Center for Connected Health Policy. State Telehealth Laws & Reimbursement Policies: A 638 Comprehensive Scan of the Fifty States and the District of Columbia

Patient and clinician 649 experiences with telehealth for patient follow-up care

Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health 652

Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus

The Center for Connected Health Policy. COVID-19 Related State Actions

AMA quick guide to telemedicine in practice

The Future of Telehealth in Allergy and Immunology Training

What physicians need to know about cyber insurance

Digital platforms heighten cyber exposures

Coronavirus Aid, Relief, and Economic Security Act

Veterans Affairs Department. Authority of Health Care Providers To Practice Telehealth 675

The Department of Health and Human Services, National 679 Telecommunications and Information Administration

American College of Allergy

684 48. The Center for Connected Health Policy. National Policy: HIPAA

How to Start Doing Telemedicine Now (In the COVID-19 Crisis

Telemedicine Technology: a Review of Services, Equipment, and Other 692 Aspects

Synchronous telehealth for outpatient allergy consultations: A 2-year regional 697 experience

Virtual health care in the era of COVID-19

Telehealth Implementation Playbook

American Telemedicine Association. Telemedicine Forms

Utilize Telemedicine: How Does Billing Work?

Medicare Telemedicine Health Care Provider Fact Sheet

HCPCS G2010). (HCPCS G2012)

Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program-Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions From the Medicare Shared Savings Program-Accountable Care Organizations-Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder Under the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act

Yes, if COVID-related (Yes, through 7/31/20)* % Yes Yes

Date range for COVID-19 PHE telehealth expansion (subject to modification)