Telemedicine in the Age of the Pandemic

The Progress Made in Telemedicine

Telemedicine has been used in general health care for about 10 years. In recent years, and especially since the onset of COVID-19, the exploration of remote delivery methods for workers compensation cases has received urgent attention. Types of workers-compensation-related services that could, for example, be appropriate for telemedicine injured workers include the following. ¹

• Triage
• Initial care evaluation
• Follow-up care for noncomplex cases
• Telerehabilitation (interactive physical therapy services)
• Psychiatric services
• Return-to-work evaluations
• Impairment ratings
• Blood-borne pathogen training
• Medication management
• Independent medical exams

During this pandemic period, many doctors turned to telemedicine to provide their patient services, and it has seemingly worked well for those with the resources. It seems likely that this previously emerging method of healthcare delivery will become increasingly common and a more pervasive form of service delivery in the future, despite how quickly COVID-19 resolves. As a result, it seems prudent to examine telemedicine more closely and assess how it has affected medical services provisions and the claim management process by extension.

Telemedicine Defined

What is telemedicine? Telemedicine is the process of delivering medical services remotely. A derivative of telemedicine is "telehealth," which involves education and monitoring using various media. Both terms are often considered under the broader label of "e-health." While these are generally recent developments, they've been emerging in various forms for decades.

For example, consider how health care was provided to astronauts as far back as the 1960s and, predictably, how the advent of the Internet in the early 2000s opened the door widely to the alternate modes. In fact, the depth and breadth of data involved in health care enable telemedicine and highlight the capacity of the Internet to handle large data volumes at increasingly faster speeds (think 5G). A more current application has been a commitment to get more and higher quality healthcare services to rural areas more effectively, though current rural Internet service is a significant limiter to this being a truly effective solution.

Telemedicine and COVID-19

While the COVID-19 crisis has had many diverse impacts on our way of life, technology is one area where we appear to have been a bit better prepared for some of those life affects versus others. Although, as of August 2020, approximately 20 percent of primary care physicians closed their practices, and further, nearly half of Americans delayed medical care due to the pandemic.

Encouragingly, telemedicine has been most helpful throughout this period. It is estimated that 16.5 million people used telemedicine services since March 2020, which was at the beginning of the pandemic. Another metric shows that "national telehealth claim lines" increased 8000 percent from April 2019 to April 2020. Anecdotally, one service provider saw a 650 percent increase in telehealth referrals during the first half of 2020. ²

As COVID-19's impact evolved, the federal government removed the more significant roadblocks to telemedicine by temporarily expanding Medicare and Medicaid reimbursements to healthcare providers for remote services. Many private insurers followed with significant effect. While seemingly temporary in intent, many believe its effectiveness will drive a more permanent transition to this mode as both doctors and patients enjoy the convenience of this often more efficient process for healthcare delivery.

Telemedicine Tools

What does telemedicine look like in practice? There are a wide variety of modes that meet the definition, most of which are built on technology tools that enable real-time audio and video communications between patients and providers, whether separated by 10 miles or 10,000 miles. Examples of services enabled this way include the following.

• Virtual check-ins through patient-specific portals that can be accessed from the Internet, automated telephonic, or real person telephony
• Remote patient monitoring tools that can measure things like blood pressure, weight (e.g., a blue tooth enabled scale), and other vitals

Limited telemedicine visits for limited validation of things like medication protocol adherence are used to maximum efficiency, whereas in the past, several hours of time (for patients and providers) may have been consumed in seeing providers in person. Broader interactions are often conducted via video tools to allow providers to see directly and look for symptoms and signs that would not be notable otherwise (e.g., skin color, eye movement, or nerve-related movements).

Before the onset of the COVID-19 crisis, several video platforms that meet patient confidentiality requirements had been approved for telemedicine and were beginning to be used. Examples of these include Zoom for Healthcare, Skype for Business, Doxy.me, and Google Meet. Since then, Apple Facetime and Facebook Messenger, among others, have been approved for service delivery of various types. Encryption and privacy modes are available on all these tools, allowing providers to meet regulatory requirements seamlessly.

Patient access to these tools is facilitated by simple designs and ease-of-use learning/training that manufacturers have realized was critical to broad adoption, especially among patient users' groups that may be less technologically inclined or adept at using with any effectiveness. The actual reliability of delivering care this way is highly dependent on the consistent and accurate transmittal of information. Failure to set up secured systems could lead to severely deleterious outcomes.

To maximize the usefulness of these alternate channels, patients can and should carefully consider their role in doing so. These considerations include the following.

• Having a reliable working computer with enough line speed for video
• Early log-in to ensure effective use of time on both sides
• Preparing ahead of time with questions and concerns for the provider
• Knowing your vital signs that may be most relevant to the treatment sought and being prepared to provide and explain them
• Knowing your medications and their specific levels and frequencies
• Including a spouse, family member, or partner to attend as a second set of eyes and ears
• Capturing provider feedback in writing so that the next steps are clear and not misunderstood (a clear advantage to the traditional office visit where your communication is 100 percent verbal)
• Leveraging the provider's online portal effectively for postvisit testing or other results
• Knowing when to insist on in-person care where it is realistically necessary to achieve the best outcomes

Regrettably, early in the pandemic crisis, emergency room visits dropped up to 50 percent in some regions. This was attributed to fear of contracting the virus, assumptions that demand would be high, or service couldn't be reasonably obtained. Overall, patient visits to doctors and hospitals fell dramatically in some cities for these and other reasons. This led to a potentially significant rise in the risk of undiagnosed and/or untreated conditions, causing serious consequences for patients who went without care not realizing that telemedicine options existed or who believed effective care could not be secured remotely.

For example, a person is 10 times more likely to die of an untreated heart attack than of COVID-19. ³ Follow-up medical care can be just as important and just as impeded for lack of knowledge about these remote alternatives. Patient education is the key to understanding what's at stake and what alternatives exist for those in need of care, especially during crisis events where fear often becomes the key motivator or demotivator to patient behavior.

Telemedicine and Workers Compensation

In the world of workers compensation, "e-health"-related services (and specifically remote taskings and activity) and care are accomplished in numerous categories, including the following.

• Clinical consultations
• Case management
• Utilization reviews
• Return to work
• Compensability determinations
• Fraud investigations
• Prescription drug administration and delivery
• Behavioral health

As in many health-related scenarios, time is often of the essence. As such, one of the key benefits of remote services is speed and convenience, which help minimize the delays that can often exacerbate recovery.

A successful telemedicine program focused on industrial injury should include the following elements.

• An employer-approved implementation plan that includes securing employee consent where required by law (e.g., California)
• Nurse triage to vet the cases for appropriate application of services
• Using a clinical consultation to ensure that each injured worker is correctly directed to the most appropriate modality of service
• Using appropriately trained, qualified, and licensed clinicians to ensure the use of reliable treatment guidelines
• Experienced providers trained to provide quality occupational care in a telemedicine environment
• Related technology and procedural logistics aligned to create an efficient and quality clinical experience
• Preidentification of the most relevant injury types that can best be treated with telemedicine. ⁴

Conclusion

As the response to the COVID-19 crisis continues and we brace for the possibility of a "second wave," telemedicine and its derivative modes are more relevant than ever. Large portions of populations continue to defer what is, in some cases, essential care that could have prevented other or worsening conditions. As this healthcare crisis continues to play itself out, regulators in several states (e.g., California, Texas, and Arizona) are loosening requirements and fee schedules while research validates an increasing willingness of patients to try remote care. ⁵

Yet, the regulatory and administrative overhang of the Affordable Care Act (ACA) and its intersection with so much of the healthcare world persists. These issues/events of COVID-19, the ACA, and patient attitudes toward their personal safety will drive the consideration of telemedicine to greater urgency and importance.