January 06, 2021

One of the first tasks of a clinician or healthcare facility when encountering a patient is to determine a diagnosis and course of treatment. Where and how will this determination be made, and by whom? With the recent promotion and extension of virtual medicine, including telehealth services, many hospital workers are wondering: when is it appropriate to utilize telehealth in this determination process? Is there a checklist that makes the decision to go virtual more supportable?

Set a Standard

Back in April of 2020, when COVID-19 was ramping up, Raleigh General Hospital announced that one of its associated medical groups was adding virtual visits to its available services. The announcement specified criteria under which a patient would be able to access such services. It began by saying, “For patients who meet certain clinical criteria . . . .” This conditional phrasing indicates that the group and/or hospital had already developed a set of clinical standards that would first have to be met before telehealth would be made available. The announcement continued: “Virtual visits may not be available in all cases and will be evaluated based on a patient’s specific clinical needs.”

All this points to an action that other facilities would do well to follow, and that is to set a standard for appropriately allowing the provision of telehealth. This, by implication, means the hospital must set certain limits as to its utilization. Decision-makers should meet and determine which patient diagnoses, conditions and proposed treatments should be funneled into the virtual silo, as opposed to those demanding an in-person encounter.

All this is well and good, but where would one begin in making such determinations? Well, rather than reinventing the wheel, it may be helpful to see what other facilities have come up with in this regard.

Begin the Process

According to a December 30 report in the New England Journal of Medicine (NEJM) Catalyst in Care Delivery, UCLA Health has been in the process of creating a set of protocols to help providers determine when it is appropriate to deliver care to patients via a virtual approach. Back in April and July of 2020, UCLA Health surveyed primary care physicians about their use of telehealth. The survey revealed that most of these providers agreed that the decision to utilize telehealth should be based on “a careful assessment of the risks and benefits associated with each approach.” The December 30 report went on to state, “Especially outside of the pandemic, when the risk of visiting a physician’s office is very low, there are circumstances in which telehealth should not be used, such as for a patient with chest or abdominal pain.” The report then went on to describe helpful considerations in devising a triage-style approach for scheduling telehealth, instead of in-person, visits. They are as follows:

Form a multidisciplinary team including clinical, operational and financial stakeholders to analyze and implement changes that increase the system’s ability to provide high-quality virtual care.
When developing triage protocols, particularly during an active pandemic surge, consider risks associated with both virtual and in-person care. Consult providers, operators and patients to identify red flags to indicate when virtual care is appropriate.
Establish performance metrics and collect regular feedback from physicians, staff and patients to continuously improve and refine triage protocols.
Of course, these recommendations are just the start of the process. You’ll also need to have a full understanding of the Medicare and commercial payer rules involving the prerequisites for, and billing of, telehealth services. For the Medicare rules, our readers are directed to the following website: Regulations & Guidance | CMS.

Develop the Details

One of the basic considerations in determining when telemedicine is warranted was advanced by the World Health Organization (WHO), which stated the following in a February 2020 advisory:

Consider using telemedicine to evaluate suspected cases of COVID-19 disease, thus minimizing the need for these individuals to go to healthcare facilities for evaluation.

So, suspected COVID symptoms is one the items you will want to include on your telemedicine triage checklist. Another may involve at-risk population groups.

Recall that the Centers for Medicare and Medicaid Services (CMS) provided waivers early on in the viral outbreak in the United States that allowed expanded telemedicine access to Medicare patients, i.e., seniors. Since most studies that seek to find contributing factors in COVID deaths have determined that the elderly are at high risk, it would seem logical to develop specific protocols for utilizing telemedicine as it pertains to this particular population group.

Consider Some Examples

According to a report by Modern Healthcare, Bergen New Bridge Medical Center in Paramus, New Jersey created a dedicated telemedicine service for COVID-19 in just “a few hours.” Here’s how it works, per the report:

Patients concerned about the virus dial a hotline for a screening with a nurse.
If the patient needs further evaluation, the nurse will then refer them to a video consultation with an infectious disease specialist.
Nurses use the CDC’s guidelines to screen patients for COVID-19, which include asking about a patient’s travel history and exposure to the virus, as well as their symptoms.
Obviously, there can limitations to telemedicine screenings. For example, clinicians wouldn’t be able to listen to a patient’s lungs without specialized equipment, and definitive diagnoses may require laboratory testing. Therefore, if hospital personnel suspect that one of these patients may have coronavirus, a staff member contacts the Department of Health to coordinate an assessment with the agency’s epidemiologist.
In another example of facility proactivity, a hospital in the State of Washington has rolled out an online chatbot that screens patients who are worried about COVID-19. The system suggests next steps, to include a telemedicine or in-person visit, depending on the severity of their symptoms.

Hospitals around the country are making use of different strategies to determine when to deploy telehealth services. If you feel your facility may be lacking in this area, you may want to explore what other hospitals are doing, including any decision trees they may have developed. One such decision tree is provided on p. 151 of a CMS resource that can be accessed by going to the following website: COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing (cms.gov).

As we begin a new year, it is our hope at MiraMed Global Services that joy and success find their way into the lives of our readers and that 2021 will be a year of great strides in the fight against disease. Please reach out to us if you have a comment or are interested in our business solutions. Simply go to info@miramedgs.com.