Telehealth to the Rescue
The coronavirus (COVID-19) pandemic is rapidly changing how health care is being delivered, most notably in the use of telehealth by both providers and consumers. Telehealth is not new, but has not been widely used.
With social distancing measures in place across the country, and a desire to keep our most vulnerable patients from being exposed to infectious diseases, it makes sense for senior living facilities to tap into this valuable resource. Added incentives for using telehealth include the March 17 announcement from the Centers for Medicare and Medicaid Services (CMS) for the temporary expansion of telehealth coverage, states following suit with expanded coverage and nearly 100 insurance providers updating telehealth offerings during social distancing.
What is telehealth or telemedicine?
The American Telemedicine Association (ATA) defines telemedicine as “the remote delivery of health care services and clinical information using telecommunications technology. This includes a wide array of clinical services using internet, wireless, satellite and telephone media.” The ATA considers telehealth and telemedicine to be synonymous.
Healthcare providers can use telemedicine to perform real-time diagnostic and treatment procedures from a distance through phone screening, virtual visits and remote patient data monitoring that can guide providers and residents in deciding when to escalate a case. Some common uses for telehealth by senior living communities include:
- Resident screening and triage for COVID-19 and influenza-like illness.
- Pre- and post-operative visits.
- Remote patient monitoring for routine management of chronic medical conditions.
- Acute office visits for conditions that can be assessed and treated remotely.
In the past, senior living communities primarily used telehealth in rural settings where access to health care providers was limited by distance. For them, equipment was either purchased or leased and stored at the facility. Telemedicine carts were equipped with such things as:
- Audio/video communications.
- Detachable camera.
- Virtual stethoscope.
- Pulse oximeter.
- 12-lead Diagnostic ECG.
- Blood pressure monitor.
- Electronic Medical Record (EMR) integration.
If urgent care is needed, the nurse at the facility wheels the cart to the resident’s bedside and calls the network provider. A physician responds and takes over control of the camera. If the cart is EKG-ready, the physician sees the readout as it happens. Vitals and labs are in real time also. The physician can prescribe, which is downloaded to the EMR instantly. All communication is HIPAA compliant and family members can be conferenced on the call. The system shows how many physicians and specialists are online and available to join the call, if needed. If the resident is sent to the hospital, the physician will communicate directly with the hospital. Physician notes are sent to the attending physician right away, plus everything is recorded so the attending physician can watch or listen to what went on.
With the overnight demand for social distancing during the COVID-19 outbreak, cloud-based software systems were rapidly contracted and licensed to mass health care providers and consumers. The advantages to these systems are that several are available on the market; most are HIPAA/HITECH compliant, easy to use and can be activated in a short amount of time. Additionally, providers can continue to offer services to seniors that were already under their care, and specialists can be brought in for consults, as needed. Besides virtual consultations, many software packages include a scheduling function, secure access to residents’ care records, medication lists and other clinical data in real time via the web or through a dedicated phone application, as well an integrated e-commerce payment system and electronic prescribing.
Risk management considerations
All 50 states have developed telemedicine regulations and state definitions; and several states have updated their regulations, policies and guidance on telehealth since the start of the pandemic. Senior living facilities should review and consider them carefully in the development of telemedicine programs.
To date, clinical and patient safety telemedicine risks remain limited and more centered around physician malpractice allegations. Potential liability risks include:
- Exam should have been performed in person rather than by video.
- Image distortion causing misdiagnosis.
- Incomplete telemedicine exam.
- Power failure resulting in delay/error.
- Negligent prescribing based on a video exam.
- Negligence in the failure to provide telemedicine support.
Senior living facilities should work with their health information management team and legal counsel at both ends of the telemedicine operation to ensure that forms, policies and procedures are mutually agreed upon and that procedures for access, maintenance and protection of records related to telemedicine services are robust and in compliance with rules governing health information and health records. Some risk management considerations include:
- A private and secure high-speed computer network (with adequate bandwidth) is maintained to protect patient confidentiality and the integrity of information exchanged between sites.
- Appropriate security measures are implemented during the transmission process that includes authentication, patient identification, data control and tracking, and Wi-Fi protected access.
- Roles, responsibilities and overall governance for the IT team are determined and clearly communicated.
- A formal process exists for obtaining informed consent of patients for telehealth services that includes full disclosure of known clinical and technical risks.
- Telehealth sessions take place in private settings that are conducive to face-to-face consultations.
- Adequate staff training is provided that includes telehealth procedures, scope of services, proficiency with the technology system and responding to equipment malfunctions.
- All provider-patient interaction using telehealth technology must be recorded in the resident’s health record – e.g., consult notes, who participated, etc.
- Telehealth procedures are regularly evaluated to ensure compliance with patient protection laws, including applicable HIPAA/HITECH and CDC, and state laws and regulation.
It’s important to remember that telehealth is not a replacement for traditional, office-based medical care, but rather an augmentation under the right circumstances. The longer the pandemic continues, the more telehealth will become ingrained in the health care system. Telehealth has incredible potential to play an important role in the future delivery of health care. Additional studies and regulation will be needed for continued large-scale use.