Telemedicine in the Time of Coronavirus.

Within weeks, COVID-19 has transformed our practice of palliative care and clinical medicine as we know it. Telemedicine has emerged as a critical technology to bring medical care to patients while attempting to reduce the transmission of COVID-19 among patients, families, and clinicians. It is also increasingly necessary to preserve scarce resources like personal protective equipment. In this article, we share just-in-time tips to support palliative care clinicians and program leaders in providing the best care possible by telemedicine. These quick, practical tips cover telemedicine setup, patient considerations, and clinician considerations. Next steps include ensuring equitable access to affordable telemedicine technology for vulnerable populations through creative solutions and financing, and dedicated attention to telemedicine evaluation and quality improvement. Published by Elsevier Inc.

Even before the arrival of COVID-19, telemedicine was increasingly being adopted to bring specialty-palliative care into the homes of seriously ill patients and their families. Patients who receive palliative care by telemedicine are typically very satisfied with the convenience and time-saving of video care. Telemedicine also saves valuable drive-time for home-visiting palliative care clinicians and increases capacity at brick-and-mortar clinics.

With the emergence of COVID-19, telemedicine has been catapulted into the role of a critically essential service for patients to help mitigate the spread of COVID-19 and preserve valuable personal protective equipment. For example, the University of California, San Francisco (UCSF) has mandated telemedicine be used to care for palliative care and nonpalliative care patients in ambulatory settings, whenever possible. Similarly, many hospice agencies are currently offering most, if not all, social work and chaplaincy support by telemedicine. For hospitals, strict limitations on visitors have meant that some inpatient palliative care consult programs are performing family meetings and consults virtually. To support these changes, many telemedicine regulatory measures are being relaxed. As of this month in the U.S., patients can receive telemedicine across state lines, Medicare will reimburse for telemedicine visits, and the Drug Enforcement Administration will allow prescription of controlled substances by telemedicine without a prior in-person evaluation.

We have developed some telemedicine quick tips based on our collective experience at UCSF and ResolutionCare Network. Although these tips are focused on the outpatient setting, many of the same principles apply when using telemedicine in the hospital.

Telemedicine Setup

The United States Department of Health and Human Services recently liberalized HIPAA compliance guidelines for the COVID-19 pandemic. It is possible to use a variety of non-public facing video communication tools, many of which are free or low cost, including, Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype. Consult with local leadership for specific institutional guidelines.

Patients need access to a smartphone, tablet, or a computer with audio and a camera as well as a data plan or Internet connection.

For patients who are new to telemedicine, identify one key contact (preferably English speaking) who can serve as the “technological liaison” for the patient/family.

When resources allow, designate palliative care program administrative staff and/or volunteers to reach out to the “technological liaison” at least one to two days before the telemedicine visit to provide setup instructions and perform a test run. Ensure the “technological liaison” is available during the scheduled visit to troubleshoot technological glitches in real time.

For programs that have a patient portal as part of the electronic medical record, a “dot phrase” that includes instructions for patients/families on how to download the telemedicine platform and prepare for the visit can be helpful. Provide this information a few days before the visit.

Depending on the palliative care program's telemedicine platform and resources, phone interpreters may be easily added to telemedicine visits. To understand available options, discuss with local program leadership and the contracted phone interpreting company.

Patient Considerations

Coach patients on telemedicine communication etiquette, especially if there are multiple people involved in the visit. Remind others to mute if they are not engaged in the conversation.

Similar to in-personal clinic appointments, set expectations with patients that the clinician(s) will sometimes run late. Have a contingency plan if the meeting does not start at the scheduled time. Consider instructing the patient to call the palliative care program if a clinician is more than 15 minutes late for a telemedicine visit. This information can be included on the introductory patient portal message and reinforced by appointment schedulers.

Despite best efforts, some patients may not be able to join by telemedicine due to lack of access to technology/Internet, insufficient social support, or connectivity problems on the day of the visit. In these circumstances, telephone may be an alternative, with some insurance plans reimbursing for telephone visits.

Consider reasons a patient needs to be seen in-person rather than by video. Examples include the following: a patient's change in condition, need to complete a cardiac or lung examination, or the inability to offer an interpreter over video.

Clinician Considerations

Create a therapeutic telemedicine environment through the following techniques:

Choose a space that is quiet, is private, and has good lighting. When possible, choose a space with a professional, neutral, and uncluttered background.

Use a laptop or desktop computer whenever possible; avoid using a handheld smartphone, which can be distracting, or even nauseating as the phone moves around.

Look at the camera (not your electronic medical record) to ensure good eye contact and foster rapport and trust.

Clinicians should orient the patient to where they are sitting and who else is in the room to reassure them the conversation is private; ask the patient to do the same.

Look for unique opportunities to learn more about patients by telemedicine and use the technology creatively.

On many platforms, multiple clinicians and/or family members can participate in the visit from separate locations.

By way of example, ask for a tour of the patient's home, meet their pet virtually, or have them share family photographs.

Perform accurate medication reviews by having your patient hold up each medication to the camera.

Brainstorm what parts of the physical examination can be performed by video (it is surprising to most clinicians how much is possible).

Pay even closer attention to subtle comments made by patient and caregivers and their body language. The clinician should ask clarifying questions if they are not sure if they heard the patient correctly or are having difficulty interpreting body language by video.

Many clinicians note telemedicine visits are shorter and more focused than in-person visits. While this can increase efficiency, creating space for patients and families to share their thoughts and feelings is arguably even more important than it was before the COVID-19 pandemic. A simple question early in the telemedicine visit like, “I know we are facing really scary, uncertain times right now. How are your spirits?” can be effective.

A recent satisfaction survey we conducted at UCSF of 35 palliative care patients and 15 caregivers who had at least one palliative care visit by telemedicine found 97.1% of patients and 100% of caregivers felt comfortable having sensitive and emotional conversations by video (BA Calton, et al. Unpublished manuscript. 2020). Do not shy away from having these conversations over telemedicine. Key communication principles like asking for permission and attending to emotion should be relied upon when discussing sensitive topics by telemedicine.

In the U.S., Medicare is now providing reimbursement for telemedicine visits conducted in both the inpatient and outpatient settings during the COVID-19 pandemic under the 1135 Waiver. Previously, many commercial insurance plans were already reimbursing for telemedicine. Billing clinicians should document telemedicine visits as they would an in-person encounter, remembering to include only the physical examination that is possible by telemedicine. Bill using the same clinic (or inpatient) CPT codes used for an in-person visit and select Place of Service “02” to specify the service has been provided by telemedicine.

Finally, it is important to be patient. Occasional technological difficulties are inevitable, and the tech-literacy of your patients will vary.

Telemedicine is a proven modality for delivering palliative care to the most vulnerable people. Care of people with serious illness and their families now requires impeccable social distancing for their protection and for all health care professionals so critically needed in response to COVID-19. Preparation, patience, and practice will help ensure effective implementation of telemedicine. The quick tips offered above are an excellent starting point, but additional support and innovation can help eliminate barriers and stimulate rapid mastery. First, we must find creative ways to ensure that all patients have equitable access to this valuable resource. We must reach individuals with poor social networks, with poor technological literacy, and who lack access to technology. Soliciting the help of volunteers, philanthropy, and tech companies who can create plug-and-play telemedicine devices at low cost can help shore up potential gaps in access. Second, reimbursement for telephone visits, particularly to those in whom video visits are not possible, will incentivize the use of this important modality when it is needed. Third, we must capitalize on this unprecedented time in which telemedicine will become a critical part of health care delivery to study processes and outcomes through programmatic evaluation and research to guide best practices in the future.