key: cord-0993875-slkgaaua authors: O'Hara, Valerie M.; Johnston, Starr V.; Browne, Nancy T. title: The paediatric weight management office visit via telemedicine: pre‐ to post‐COVID‐19 pandemic date: 2020-07-06 journal: Pediatr Obes DOI: 10.1111/ijpo.12694 sha: 89f8e862c676c9fbd8d32db89c4aa858a836dde2 doc_id: 993875 cord_uid: slkgaaua Telemedicine is a powerful tool that erases many logistical barriers to care and may increase access. Due to the need for social distancing, the COVID‐19 pandemic has temporarily reduced in‐person visits for clinical care. Providers, clinical staff and patients are pressed to acutely learn new skills and adapt clinical care through the use of telemedicine whilst administrators, policy makers and regulatory organizations make changes to existing policies to meet this national emergency. Our tertiary care, interdisciplinary paediatric weight management clinic began the use of telemedicine 5 years ago to bring access to an underserved, rural population at their primary care office, which has allowed our clinic to pivot seamlessly to in‐home telemedicine visits during the pandemic. Telemedicine rules and regulations are rapidly changing to meet the COVID‐19 national emergency, but many supports for new telemedicine providers are already in place. In this article, we provide an overview of telemedicine components, policies and regulations. We review the operationalization of our clinic's telemedicine visit prior to the pandemic. We discuss how telemedicine services are impacted by COVID‐19 and key resources are provided. Finally, we reimagine telemedicine services post‐pandemic to expand effective, coordinated health care, particularly for patients with chronic needs such as obesity. The arrival of the COVID-19 pandemic has significantly affected traditional healthcare delivery systems. The need for social distancing along with the on-going needs of our patients demanded that healthcare professionals create in-person visit alternatives. The COVID-19 pandemic has created an urgency to act, to use every tool in order to treat safely. Swift policy and regulatory changes such as reimbursed telemedicine visits directly to the patient's home have occurred at state and federal levels to provide access between patient and providers. Hospital systems and professional organizations are mobilizing teams to support telemedicine efforts, including virtual meetings, links to resources and rapid adaptation of policies and skills. Government agencies, particularly the Centers for Medicare and Medicaid Services (CMS), are reacting to the evolving emergency with telemedicine waivers and rule changes to allow continuity of care in provider practices. 1 As practitioners in a tertiary care, interdisciplinary paediatric weight management clinic who have conducted telemedicine visits for 5 years, we see an opportunity to offer assistance, resources and encouragement to colleagues. In our experience and in the literature, families and paediatricians express positive feedback and support for telemedicine. [2] [3] [4] Providers recognize the need to continue care for patients with obesity who are at risk for increased severity of COVID-19 disease perhaps due to factors directly related to obesity pathophysiology and/or the chronic comorbidities of obesity. 5 Chronic disease requires on-going management; interruption of chronic care visits for obesity delays treatment and can lead to increased disease burden and poor outcomes. The changing healthcare delivery environment demands creative thinking to best utilize telehealth in the COVID-19 era, particularly for patients with the chronic disease of obesity which requires high intensity, high-frequency interactions across an interdisciplinary team. [6] [7] [8] The purpose of this article is to review basic components of telemedicine followed by a discussion of operationalization of a virtual visit prior to the pandemic as used by our paediatric weight management clinic. We review how COVID-19 has impacted telemedicine services and key resources are provided. Finally, we reimagine telemedicine going forward to expand effective, coordinated care particularly for patients with the chronic disease of obesity. In 2009, our interdisciplinary paediatric weight management clinic located in a tertiary medical centre began obesity medicine services for referrals within our rural geographic area. Primary care colleagues practicing in a remote area of the state 4 hours from our clinic expressed frustration that our clinic's level of obesity care was not reasonably available to their patients due to financial, weather and travel barriers. In 2015, after a series of meetings with both facilities' administrators, clinicians, information technology (IT) experts, state Medicaid and telehealth representatives, we implemented a plan to provide telemedicine services from our weight management specialty clinic to the remote primary care provider's (PCP) office. Board of Obesity Medicine certified medical director, RN coordinator, nurse practitioner (NP), registered dietitian (RD), paediatric developmental psychologist and personal trainers. Team members complete continuing education in obesity medicine annually. Our telemedicine plan called for the initial patient evaluation by the physician and nurse coordinator to be in-person with subsequent team member visits provided using telemedicine at the patient's PCP office with no changes to our overall programme protocol. Structuring the initial visit in-person was a curriculum decision specifically designed to develop provider/patient relationships and to conduct a thorough physical examination. New referrals at the originating site are scheduled quarterly (or more frequently if volume dictates). Initial visits are 1 hour per provider (physician with nurse coordinator, RD, paediatric developmental psychologist, trainer); follow-ups with each provider are scheduled for 30 minutes on average (pending patient complexity). The curriculum progresses from eight weekly, eight bi-weekly, to six monthly visits followed by continuing maintenance appointment intervals determined in collaboration with family and team. The patient sees the physician/NP provider, RN coordinator and trainer at each visit. Patients are seen by the RD and psychologist every 3 months (more frequently as needed). This schedule is designed to provide required high intensity and frequency that meets the 2017 US Preventive Services Task Force (USPSTF) recommendations (26 hours of intervention over 12 months). 6 Baseline assessments by team members are used to develop individualized medical, educational and behavioural goals. The programme is on-going to meet the needs of children with a chronic disease. In 2017, Tuckson et al listed five trends that would propel telehealth forward: consumer technology market innovation, electronic health record advances, healthcare worker shortages, incentives to deliver healthcare in lower cost settings and consumer expectations for realtime access to health services. 9 These trends are magnified with the urgency of the COVID-19 pandemic and the increased demand for the flexibility of telemedicine within health care. Telemedicine services expand access by reducing barriers such as travel time, competing responsibilities, absence from work (less travel time which can be 2-4 hours) and inclement weather. Advantages for providers include schedule flexibility by seeing patients from one venue rather than travel to various clinic locations. Institutions may find increased productivity and less clinic overhead. Telehealth is a global term encompassing the delivery of health care, education and information by remote technologies. 10 Telemedicine, a subset of telehealth, uses technology to connect a patient and healthcare provider in separate locations in two-way, real-time interactive communication. 11 The patient's location is termed the originating site; the provider's location is termed the distant site. Pre-COVID-19, originating sites were limited to healthcare facilities per CMS rules but during the COVID-19 pandemic, the originating site is allowed to be the patient's home as a covered service. Telehealth technology must meet the clinical needs of a particular practice. Ranging from simple to complex, an abundance of diagnostic tools adapted for telehealth exist but are often underutilized. Examples include remote patient monitoring, technology-based communications such as e-consults and brief virtual visits, Project ECHO casebased provider-to-provider learning and video (telemedicine) patientto-provider visits. [12] [13] [14] An understanding of terminology is important in navigating best practice usage of telehealth tools. Table 1 provides common telehealth and telemedicine terminology and definitions. Organizations that support providers and institutions with real-time knowledge of current telemedicine technology, regulations and rules are listed in Table 2 . Available telemedicine platforms will vary across practices and institutions. Each institution must ensure that their chosen platform is Health Insurance Portability and Accountability Act (HIPAA) compliant providing security to both providers and patients. Although many of these restrictions are currently waived under the public health emergency, it is advisable to implement a platform which meets HIPAA regulations, both to ensure the security and privacy of patients, and to proactively prepare for the return of previous restrictions. At our institution, administration, legal and IT teams chose telemedicine platforms and developed policies around telehealth use. Our current platform offers an institutional professional user license that is HIPAA compliant and secure per our institution's policies. A business associate agreement is in place between our organization and the technology vendor. Providers offered input into needs for clinical work provided via telemedicine after reviewing and testing available options. 13 Our telemedicine experience is between separate hospital clinics in the same healthcare system at different geographical sites. Hospital administrators and legal teams from both sites, even though members of the same hospital system, created a joint contract detailing scope and division of responsibilities. If working with sites located in different healthcare systems, there will likely be additional considerations such as licensure and credentialing particularly if located in different states. Prior to the COVID-19 pandemic, CMS set specific requirements outlining that the originating site must be a healthcare facility that met rural eligibility requirements with few exceptions. Fifty state Medicaid programmes reimbursed some form of a real-time video visit; however, the amount of reimbursement varied from state to state with some states requiring payment parity (payment equal to in-person service) and some only coverage parity (payment less than in-person service). The list of services eligible for telehealth under Medicare and many state Medicaid policies was quite limited in scope. Although CMS provides oversight for both Medicare and Medicaid, states have significant flexibility with respect to defining and implementing policy for telehealth coverage, and in many cases state Medicaid policies have allowed for much broader use of telehealth than Medicare, which prior to COVID-19, had tight restrictions on eligible patient locations, services, providers and modalities. Previous to the pandemic, there had been a trend in state Medicaid programmes to expand the list of eligible patient (originating) sites outside the healthcare environment, to include schools, worksites and patient homes, in order to promote broader access to care and increased utilization of telehealth. Maine's Medicaid programme has been a leader in this regard and has allowed the patient home as an eligible originating site since 2018. Since the declaration of the COVID-19 national emergency, Medicare payments for telemedicine services are now equal to payments for in-person visits and a majority of state Medicaid programmes have followed suit. 16 The list of eligible services has significantly expanded for both Medicare and Medicaid programmes, under various blanket waivers and emergency orders. 17, 18 CMS has relaxed originating site restrictions to include the patient's home as well as expanded which providers and services are allowable via telemedicine during the pandemic. 1 Originally, our state Medicaid programme (MaineCare) required initial prior authorization for telemedicine services followed by annual authorization renewal. In 2016, this requirement was removed after provider feedback asserted that the requirement created significant delays in providing telemedicine services and limited telehealth utilization. This important policy change, along with removal of geographic restrictions, created significant re-engagement from early telemedicine adopters and leadership in our state. 15 The policy further confirmed that a service that could be safely delivered via telemedicine (as determined by the healthcare provider) and was covered by MaineCare in the in-person setting was eligible for telehealth service coverage and reimbursed at the same rate as the in-person service (payment parity). 15 Laws governing reimbursement for telehealth services by private insurers exist in 41 states and the District of Columbia. 16 However, payment parity for telemedicine visits compared with in-person visits is not guaranteed across individual insurers and policies and not all laws mandate reimbursement. Some policies use language such as 'may' vs 'must' and some specify that telemedicine services are reimbursed at a lower percentage. Overall, under the COVID-19 pandemic, private payors across the United States are following suit with Medicare and Medicaid programmes in providing payment parity. Definition of telehealth terms 11, 15 Term Definition The full credentialing option requires providers from the distant site to undertake the entire credentialing process at the originating site. This methodology is time consuming but approval does allow the distant site provider to conduct in-person visits at the originating site. Our practice utilizes this methodology in order to perform the new patient encounter at the PCP office (originating site). The by-proxy credentialing option allows originating sites to accept the credentialing of the distant site where the provider already has existing privileges to allow for telehealth services but not in-person visits. Credentialing time is reduced using this methodology; however, some institutions are reluctant to use this process due to legal concerns around liability of credentialing accuracy. 19 Although institutions credential professional staff for practice privileges, individual states are responsible for granting professional licenses. Prior to COVID-19, practitioners needed a valid license in the state where the patient was physically located regardless of the provider's location. During the COVID-19 pandemic, a majority of states are waiving these laws or providing mechanisms for emergency licensure for medical providers. 20 Space utilization will be different for each originating/distant site collaboration depending on resources and overall organization of clinical care. In our case, two exam rooms were set aside for patient visits to ensure privacy and maximize the number of patients seen by our multiple providers. Pre-COVID-19, a telemedicine consent form was required for Medicaid patients outlining that receiving care via telemedicine was optional. If patients preferred to be seen in person, this type of visit would be provided. The consent to receive care using telemedicine was also reviewed for privately insured patients. During the pandemic, all visits are now via telemedicine and consents are obtained verbally with appropriate documentation in chart. As a paediatric practice, issues of consent to treat and who is present during the visit are the same for in-person or telemedicine visits. 24 Our goal is to make the telemedicine visit as easy as possible for the patient and family. Thinking through the desired goals and components of the visit improves quality and flow. The initial team member starts the telemedicine session and the patient/family is 'invited' securely into the visit by the provider. Subsequent team members are then invited into the virtual exam room in turn. This strategy allows the patient/family to continue to be in the virtual exam room throughout the visit with team members joining and leaving. This strategy works regardless of how few or many team members may be virtually joining the visit that day. Prior to our clinic's expansion via telemedicine services, providers developed many educational tools, handouts and interactive games for traditional in-person visits. Being able to continue to utilize these resources required the team to develop effective ways to incorporate education tools using the telemedicine platform. We successfully addressed this challenge through use of our online platform's share feature allowing providers and family to view educational materials simultaneously and discuss the content. All families received a complete hard copy of the curriculum educational binder at the initial visit which is kept in their home for on-going reference. In addition to standard documentation practices, providers documented how the visit was conducted, who participated in the visit, and where the patient visit occurred. Frequency for patient consent is the same for telemedicine services as it is in-person (eg, annual consent). All charges, scheduling, insurance, consents and questionnaires from the patient visit were scanned from the originating site to the distant site for entry into the distant site's electronic medical record negating the need for most paper documents. A locked boxed is recommended for the provider to utilize when travelling between sites if needed. The 95 or GT modifier (depending on payer directive) is added to evaluation and management (E&M) codes to highlight that the documented service was provided via interactive telemedicine. 25 The originating site, if it is a healthcare facility, bills the facility fee by submitting a Q code (Q3014). Frequent telemedicine codes are listed in Table 3 . Patients covered by private insurers are counselled to review coverage for telemedicine services with their insurer due to the coverage variability. In our experience, telemedicine services are covered by most private payors at rates comparable to in-person services. Patients are responsible for telemedicine visit co-pays similar to inperson visits per their insurance policies rules. In our state, any licensed provider in good standing can provide a service within their scope of practice via telemedicine if that service is covered in the in-person setting. 15 RD and behavioural health providers bill for their visits noting within their documentation that the service was provided via telemedicine. Patients are able to see more than on provider on the same day. 15 Appendix lists additional best practices through our experience. including what is telemedicine, how and why it is used and how will the clinic support the family to use the service. 28 The coordinator emphasizes that telemedicine is a voluntary service and that the family can opt out initially or at any time during treatment. Risks and benefits are discussed prior to consent for telemedicine treatment. Educational materials covering how to access the telemedicine platform, tips for use and answers to frequently asked questions are provided to the family and assistance is offered by the clinic as needed. Under COVID-19, CMS has waived written consent requirements under blanket waivers and many states have waived written consents as well. Consent is verbal when the telemedicine visit is in the patient's home. It remains good practice to document verbal consent in the chart and to secure the written consent as soon as feasible. During COVID-19, innovation and creativity are growing and will Acquiring accurate vital signs and weight are key concerns especially as these data impact medical decisions and management. Reassessment of clinic protocols requires creative problem solving by prioritizing risks and benefits in obtaining data during the pandemic. Pulse, blood pressure and weight may be obtained by home blood pressure cuffs and scales. Many families already own these items, but for those who do not, we have received grant support to provide these items to families. Other remote patient monitoring Table 3 See Table 3 Facility fee CMS Institutional policies See devices are available for more specific needs. 13 Many elements of the physical examination can be completed effectively via telemedicine with peripheral monitoring devices and/or patient selfreported data. As medical providers, we have counselled and taught many skills to parents in order to manage chronic diseases together. Ideally, providers will strike a balance between measurements from home and clinic to best monitor data over time. Pre-COVID-19, the overall patient volume via telemedicine was approximately 10% of our clinic's entire practice with minimal financial impact on the overall clinic. During the pandemic, providing 100% telemedicine will clarify the variance between the pre-COVID-19 fee structure of in-person visits at a healthcare setting (professional and facility fee) vs professional fee only charge associated with telemedicine. There is likely a 'sweet spot' to finding that balance representing an area of needed research. It is uncertain which rules and regulations will remain or be re-instituted when the pandemic is considered resolved although some states are proactively working towards sustaining at least some of the current policy expansions to better leverage telehealth technology as a means to improve access and outcomes moving forward. This resolution will take time and it is unlikely telemedicine practice will return to the previous status quo. Many patients and families receiving obesity care will appreciate the flexibility and access provided by telemedicine, particularly in their home, creating new expectations for telemedicine's on-going use as a standard of care. 9 How to safely and effectively incorporate telemedicine into existing treatment strategies for obesity is an area for future research. Telehealth and telemedicine can no longer be viewed as a luxury and potential for future use. [30] [31] [32] For those currently providing comprehensive obesity care and facing multiple barriers, including access and sustainability risk due to high attrition rates, telemedicine may provide an untapped resource and open significant opportunities. 33 As we aim for precision medicine, telemedicine allows for access in the home environment where some patients are most comfortable. Research clearly demonstrates that patients with obesity experience weight bias by healthcare providers and experience social isolation. 37 Telemedicine may provide a vital bridge to these patients in a way traditional in-person visits cannot, offering an opportunity to build trust in their healthcare providers whilst in the safety and comfort of their own homes. The COVID-19 pandemic has pushed many providers outside of their comfort zones, requiring a re-examination of incorporating telemedicine into their practice. Providers and patients will likely experience many 'new normals' in health care as a result of COVID-19. The hope is to harness this experience to improve care, increase access and better prepare our health systems for future emergency scenarios. A balance must be struck between necessary in-person visits that may be preferred by some patients and telemedicine visits. Payment models require improvement to address sustainability of both models used independently or in combination. 38 Now is the time to reimagine how we bring our expertise to patients, expanding outside a physical office building as a means of improving patient care. In the coming months, lessons learned from patients, healthcare providers and colleagues in policy, insurance, law and healthcare administration will guide telemedicine policy and programme development. Families allow us into their lives and now their homes. As their interdisciplinary providers, we strive to provide quality care for the disease of obesity. Telemedicine is an additional mechanism allowing paediatric weight management specialists to individualize treatment for youth with obesity. Connecting to a patient and seeing the response on their facethat we can make a differenceis a privilege and the ultimate reward. Why telemedicine? Increases access to care Obesity medicine: opportunity to meet USPSTF contact hours for high-intensity and high-frequency encounters associated with improved outcomes Receives positive reviews from providers and families particularly during COVOD-19 social distancing orders Assists in maintaining visits that are novel and interesting Allows for innovative use of online activity programmes during visit that can be used between appointments at home Encourages team innovation in all aspects of care Optimizing telehealth strategies for subspecialty care: recommendations from rural pediatricians Pediatrician attitudes toward and experiences with telehealth use: results from a national survey [published online ahead of print Telemedicine: Pediatric Applications Obesity and its implications for COVID-19 mortality Screening for obesity in children and adolescents: US preventive services task force recommendation statement Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report Algorithm for the assessment and management of childhood obesity in patients 2 years and older Telehealth Implementation Playbook The National Consortium of Telehealth Resource Centers General Provider Telehealth and telemedicine toolkit Department of Health & Human Services. MaineCare Benefits Manual: Telehealth Services Center for Connected Health Policy. State telehealth laws and reimbursement policies report List of telehealth services covered by CMS during COVID-19 COVID-19 related state actions Benefits and barriers to telehealth credentialing by proxy US states and territories modifying requirements for telehealth in response to COVID19 Coronavirus waivers and flexibilities Assessing patient safety in a pediatric telemedicine setting: a multi-methods study Informed consent in decision-making in pediatric practice Coding for telemedicine services Medicare telemedicine health care provider fact sheet Medicare Coverage and Payment of Virtual Services: You-Tube Video Ethical practice in telehealth and telemedicine CMS flexibilities to fight COVID-19 Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: a call to action Virtually perfect? Telemedicine for Covid-19 Telemedicine 2020 and the next decade Telemedicine and pediatric obesity treatment: review of the literature and lessons learned Zooming towards a telehealth solution for vulnerable children with obesity during COVID-19 Using telehealth to remediate rural mental health and healthcare disparities Lifeline program for lowincome consumers Weight stigma as a psychosocial contributor to obesity Telehealth for global emergencies: implications for coronavirus disease 2019 (COVID-19) The paediatric weight management office visit via telemedicine: pre-to post-COVID-19 pandemic The authors would like to acknowledge Danielle Louder, Co-Director -MCD Public Health, Director -Northeast Telehealth Resource Center, for sharing her knowledge and expertise in her content review of this article. Nancy T. Browne https://orcid.org/0000-0002-5728-6623 No conflict of interest was declared. All authors were involved in writing the article and had final approval of the submitted and published versions.