When the pandemic made its debut in March 2020, our lives were impacted in many
ways. Stay-at-home and work-at-home orders proliferated widely across America
and the world. Healthcare providers and doctors closed their doors and explored
ways to serve their patients more safely.
How this current state that continued (now months later) will evolve is hard
to say. Much of day-to-day activities are moving back toward an ever-changing
new "normal," but there is much doubt about when or if the new normal
will be clearly defined.
Among many activities of life, how we secure healthcare services has been
altered. In past pandemics, some alterations to life were primarily temporary.
This pandemic has significantly pervasive changes and infers they are more
likely to last or even become permanent over time. How the healthcare system
will function in the future remains to be seen, especially as it relates to the
up-close-and-personal aspect typical in doctor office visits, even for routine
general care. More intimate services—such as how surgeries will be
administered—may be subject to even more that are impacted by this current
crisis.
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.