20 minute read
and products used in the physician office?
from REP Feb 2022
Telemedicine: What’s Ahead in 2022?
How will it affect procedures performed and products used in the physician office?
By Mark Thill
Telemedicine soared in 2020 due to the pandemic. Usage has plateaued since then, but it’s a safe bet it’s not go-
ing away. And with it comes questions. What role will it play in urgent care and chronic care management? Will it lead to fewer in-person visits, or more? Will it change the type – and number – of procedures performed in the clinic? How about the type – and volume – of medical supplies, devices and equipment used there?
“We don’t pretend to read all the tea leaves; but we believe the right ecosystem is a hybrid model,” that is, a combination of face-to-face and virtual visits, says David Houghton, M.D., MPH, chief of the Division of Movement Disorders at Ochsner Health in New Orleans and head of the health system’s telemedicine and digital health initiatives. “That means providing the level of care that is appropriate every time and providing patients with accessible and available technology that complements the important patientprovider relationship.”
Video or audio telemedicine can offer access to a clinician for patients who lack transportation or who can’t take time off from work, according to researchers from Kaiser Permanente Division of Research, Oakland, California. “Still, it is unclear whether telemedicine visits adequately address the patient’s clinical concern, are more likely to require subsequent followup outpatient care, or are more likely to be followed by a serious health event that requires an emergency department visit or hospital stay,” they wrote.
Legislative and regulatory boost
Regulatory and legislative adjustments in response to the pandemic boosted telemedicine in early 2020. The Centers for Medicare & Medicaid Services used emergency waiver authorities to expand access to telehealth services, including waiving geographic restrictions and allowing beneficiaries to receive telehealth in their homes. Additionally, the HHS Office for Civil Rights relaxed enforcement of Health Insurance Portability and Accountability Act (HIPAA) privacy requirements for videoconferencing.
Physicians enrolled in the Medicare program licensed in any state were granted the authority to provide telehealth services to people anywhere in the U.S. if the state allows it.
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The waivers also allowed physicians to practice from home. What’s more, CMS’ Interim Final Rule allowed for payment for audio-only evaluation and management (E&M) services. In November 2021, CMS announced it would continue to reimburse providers for extended Medicare telehealth services through Dec. 31, 2023.
These regulatory changes brought about desired results. The share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million. And in July 2021, McKinsey & Company released a report showing that telehealth utilization had stabilized at levels 38X higher than before the pandemic.
American Medical Association 2020 survey data demonstrates a dramatic upswing in the use of telehealth between 2018 and 2020: ʯ In 2020, 79% of physicians worked in a practice that used telehealth compared to only 25.1% in 2018. ʯ The percentage of physicians who used telehealth to manage patients with chronic disease or to diagnose or treat patients also increased (9.9% to 59.2% and 15.6% to 58%, respectively). ʯ Twenty percent of physicians said their practice used remote patient monitoring, up from 10.4% in 2018. ʯ Sixty-seven percent of physicians worked in a practice that used phone call visits with patients in 2020. ʯ Fifty percent of physicians were in a practice that used telehealth to provide care to patients with acute disease and 34.3% to provide preventative care.
All that said, a plateauing of usage has occurred. In September 2021, FAIR Health reported that telehealth utilization, measured as a percentage of all medical claim lines, fell from 5% to 4.5% nationally from May to June 2021. By comparison, telehealth utilization rose 2% nationally the previous month, following decreases each month from February to April.
Telemedicine by specialty
American Medical Association survey data demonstrates a dramatic upswing in the use of telehealth between 2018 and 2020. The practicelevel use of videoconference and phone visits was over 75% in cardiology, endocrinology/diabetes, gastroenterology, nephrology, and neurology. In addition, the AMA survey data showed: ʯ Hematologists/oncologists had a high rate of videoconference visits (88.5%) but were less likely than other medical specialties to report the use of visits by phone (68%). ʯ Endocrinologists/diabetes physicians were the most likely to report use of telehealth to diagnose or treat patients (71.9%), manage patients with chronic disease (92.1%) and provide preventative care (52.6%). ʯ More than half of gastroenterologists, nephrologists, and neurologists said their practices used telehealth to provide acute care. ʯ Thirty-three percent of medical specialists said their practices used remote patient monitoring. This was driven by high rates of use among cardiologists (63.3%) and endocrinologists/diabetes physicians (41.6%).
Other changes from May to June 2021 involved the top five telehealth diagnoses: ʯ Joint/soft tissue diseases and issues rose from No. 4 to No. 3. ʯ Acute respiratory diseases and infections rose nationally from No. 3 in May to No. 2 in June. ʯ Urinary tract infections appeared in fifth place among telehealth diagnoses in the South in June 2021.
This was the first time since the start of the pandemic in March 2020 that this diagnosis appeared on any regional or national list, although it had been common on the lists prior to the pandemic.
ʯ Mental health conditions remained in the No. 1 spot among telehealth diagnoses.
Primary care
“Clearly telehealth has been embraced by physicians of many specialties and their patients,” says Christopher Garofalo, M.D., owner of Family Medicine Associates in South Attleboro, Massachusetts, and chair of the Massachusetts Medical Society Committee on Sustainability of Private Practice. “We saw a large increase in the use of telehealth visits in our private family medicine practice, using the visits for both acute and follow-up care.” (In March 2020, the Massachusetts Medical Society co-founded The Telehealth Initiative, designed to support physicians implementing telehealth. Other cofounders were the American Medical Association, Florida Medical Association, Texas Medical Association and the Physicians Foundation.)
“At the start of the pandemic we used telehealth to provide some Medicare Annual Wellness Visits, as the physical exam is quite limited, and even for some annual checkups for adults and well-child checks,” says Garofalo. In 2021 the number of telehealth visits decreased to around 10% to 15% of all visits and were conducted only for acute and follow-up care. Even so, he predicts that telehealth visits “will be overall higher than prior to the pandemic, but not as high as we saw early on in the pandemic.”
Garofalo saw a greater uptake of telehealth among his primary care colleagues than among subspecialists. “That’s to be expected, as primary care has a smaller number of visits that are procedures,” he says. Even so, he saw office notes from most of his subspecialists, especially, early in the pandemic, as most elective procedures were on hold. Certain subspecialists, such as GI and neurology, had more telehealth visits than more “hands-on” specialists, such as those in dermatology and orthopedics.
“One of the great advantages of telehealth is that it often brings us directly into the home environment of the patient and their family,” says Garofalo. “We can ask them to get their medicine bottles and look at them, rather than relying on handwritten notes. We can ask them to move the phone or the laptop camera to give us a view of their environment, which can help inform us if there a lot of clutter or poor lighting that may increase their fall risk. We can take a virtual look into their kitchen cabinets and refrigerator to help assess dietary habits.”
Impact on in-office visits
Ochsner Health’s Houghton has found that telehealth – including remote monitoring – has improved the quality of in-person primary care visits. “I know the work done by the digital medicine team has taken care of the patient’s most pressing conditions, so I can focus on the immediate reason for the visit, whether it’s back pain, an orthopedic issue or a behavioral health issue. I can focus on the patient-doctor relationship, because I know that the other work is being done continually.” And it’s being done better, he adds. “Because of digital medicine, we don’t just work with a handful of blood glucose readings; now we have dozens. We have 30 or 40 times the amount of data and we can manage the patient not only reactively, but proactively.”
Definition of terms
The word “telemedicine” means different things to different people, but the Centers for Medicare & Medicaid Services refers to three main types of telemedicine services: ʯ Telehealth visits. Routine office visits provided via video (requires synchronous, real-time audio and/or video communication) with new or established patients. ʯ Virtual check-ins. Short patient-initiated communications with a healthcare practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. ʯ E-visits. Non-face-to-face patient-initiated communications with a healthcare practitioner through an online patient portal
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Telemedicine may lead to fewer diagnostic procedures in the office. Kaiser Permanente researchers reported in November 2021 that laboratory tests or imaging were ordered in 59.3% of office visits, compared with 29.2% of video visits and 27.3% of telephone visits. Medication was prescribed more often in the clinic – 60% of visits compared with 38.6% by video and 34.7% by telephone. The differences could be due to patients choosing to see their doctor in person when the severity of their medical complaints was higher, they said.
Regarding other diagnostic tools, such as EKGs, stress tests or pulmonary function tests, “I haven’t seen these types of diagnostics move out of the office setting,” says Garofalo. “Some test results, such as PFTs, are much improved by having office staff educate and coach the patient. I also am not sure that EKGs will be replaced in the traditional sense. While a single-lead EKG reading on a remote device can be helpful for very basic monitoring of certain conditions such as atrial fibrillation, patients with acute cardiopulmonary symptoms will still require a 12-lead EKG in the office to help triage and determine best medical management.”
Kinks
Telemedicine is an evolving science, with kinks to straighten out. A survey-based study published in December 2021 showed mixed feelings about telehealth visits on the part of older patients with chronic kidney disease as well as their care partners and clinicians. Patients reported concerns that their home diagnostic equipment was not as accurate as professional equipment at the clinician’s site, and they complained of a loss of social connection with their clinician.
Meanwhile, clinicians in the survey viewed telehealth as compromising quality care due to an inability to conduct physical examinations and laboratory tests, including inaccurate edema and blood pressure measurement. They also reported poorer telehealth experiences with older patients, those from low socioeconomic status, patients with limited health literacy or a hearing impairment, and non-English-speaking patients.
Both clinicians and patients in the survey noted technical challenges too, such as spotty internet connectivity and application issues. However, all described telehealth as more convenient, less costly, and more efficient for patients than clinic visits. “Our findings … suggest that telehealth may best supplement rather than supplant in-person visits for patients who are older and chronically ill,” said the study’s authors.
One of the pre-pandemic limitations that hampered the use of telehealth was lack of reimbursement from payers, including Medicare and Medicaid, says Dr. Garofalo. “For telehealth to remain a successful option for physicians and patients, it is imperative that a telehealth visit be reimbursed at parity and in the same manner as an in-office visit.”
When asked what impact virtual care might have on point-ofcare testing, lab expert Jim Poggi of
Tested Insights LLC says, “I think it depends on whether the physician practice is offering the virtual visit or whether the patient is using one of the many ‘pop-up’ online services. Will telehealth and virtual visits change where patients receive future care? Probably to some extent. They are a new gateway to healthcare, for sure. I have concerns about whether they impede progress on antibiotic stewardship and how broadly telehealth visits are used.”
More than 23,000 patients have voluntarily opted to use Ochsner Health’s telemedicine and virtual medicine initiatives. Participation is voluntary on the part of physicians too. Rather than making them mandatory, Dr. Houghton and the Ochsner team intend to continue encouraging participation by presenting ongoing proof that the programs work. High HEDIS scores for telehealth visits are testament to their effectiveness and patients’ experience of care. “When physicians see this, they ask, ‘Why wouldn’t I want my HEDIS scores to be better?’”
Among Ochsner’s patients, satisfaction with telemedicine is high, as reflected in net promoter scores, which measure the loyalty of customers (patients) to an organization. “Some of the early euphoria around telemedicine has waned, as both patients and providers became more experienced and critical,” says Houghton. “But our scores have remained high, even among our most vulnerable patients, including those who are economically disadvantaged and those with comorbidities. The fact that the programs offer a lot of touches has been the driver,” he says. “We will never have to make participation a requirement.”
Telemedicine’s digital cousin: Remote patient management
In 2015, Ochsner Health in New Orleans launched the Hypertension Digital Medicine program, which provides digitally enabled chronic disease management to patients with hypertension. The voluntary program serves approximately 13,000 individuals across 10 states.
As explained in a 2021 American Medical Association report, “Moving Beyond Dollars and Cents in Realizing the Value of Virtual Care,” each program enrollee is assigned a care team (clinician, pharmacist and health coach) responsible for providing education, medication reconciliation and management, and lifestyle recommendations according to established hypertension treatment guidelines. Custom visual tools developed within the electronic health record display the enrollee’s social needs, trending blood pressure over time, hypertension-related comorbidities, patient activation level, health literacy and relevant lab results. Program enrollees are asked to submit at least one blood pressure reading per week.
Care team members contact enrollees regularly by phone and review readings and treatment options for improving blood pressure control. Enrollees are encouraged to work with the care team to co-create the treatment plan by choosing among various lifestyle and medication options. Each enrollee receives a monthly report on their progress and tips for achieving better blood pressure control. Information about the enrollee’s progress is also available to their primary care provider.
Ochsner reports the following statistics:
ʯProgram enrollees achieved greater blood pressure control compared with a propensitymatched group that received usual care (79% versus 26%). ʯ Medication adherence improved 14% among patients in the Digital Medicine program and declined 2% among patients receiving usual care over the evaluation period of six months. ʯ Program enrollees had more frequent interactions with their care team and more blood pressure measurements recorded in the EHR compared with matched patients assigned to usual care. Current enrollees submit, on average,
4.2 blood pressure readings per week. ʯ Ochsner reports that the program has enabled primary care clinicians to provide an elevated level of support to patients, which has enhanced clinician satisfaction. ʯ The program saves $77 per member per month compared with usual care. ʯ A recent evaluation found that primary care physicians experienced a 29% reduction in the number of in-clinic visits from participating patients.
Primary care clinicians reported the program helped reduce their workloads and enabled them to expand access to other patients.
Healthcare Equipment Delays? Channel Partnerships Can Help!
Opening a new clinic or ambulatory surgery center on-time is always wrought with many challenges, including equipment lead times, construction delays, product loss/damage, and getting required biomedical checks
completed. During the Covid-19 pandemic these challenges have become amplified. Demand is high, raw materials diminished, and logistics are bottlenecked all over the world. Lead times have lengthened considerably, including not only the healthcare equipment needed for a new healthcare facility but also construction materials. Exacerbated workforce shortages caused by the pandemic affects many phases of the supply chain, including manufacturing, planning, purchasing, warehousing, assembly, delivery, and biomedical start-up checks.
When faced with these new challenges, the healthcare supply chain responded in many constructive ways. Collaboration between manufacturers, distributors and customers intensified, and many innovative solutions evolved to meet ambitious construction deadlines. One of the harder hit product categories during Covid-19 was the Storage Solutions sector. Most stainless steel, chrome, and plastic, the three most prevalent storage materials, come from outside the US. Lead times for most items were approximately four weeks prior to Covid-19. They have increased to more than four months over the last two years.
CME Corp is an equipmentcentric full-service distributor that offers turn-key solutions for new construction projects. Metro is the world’s leading manufacturer of storage equipment. They teamed up these past two years to innovate some storage solutions and meet some very tight timelines for their mutual customers.
Nevada Ortho Clinic Needs Equipment in Eight Weeks
Late in 2020, when the healthcare supply chain was really starting to
Metro top track system
feel the effects of the Covid-19 pandemic, a new 18 room orthopedic clinic was built in western Nevada. The equipment needed for the new clinic was ordered in mid-December, with a go-live date in mid-February, a tough timeline in even the best of times! They ordered a Metro top track system for their storage needs. When the order first was submitted, the system was backordered until midMarch, which was not acceptable to the customer. Metro, CME, and the customer got together to strategize on how to meet this near impossible goal. Metro shipped in temporary loaner carts and prioritized/expedited the top tracks. Since items were shipped piecemeal, CME had to deploy their installation team several times to complete the install. They had enough shelving configured early enough so the clinic could stock most of their supplies. The installation took three deliveries over a two-week period, the last delivery being on the day the clinic opened. CME’s install team went beyond the call of duty, as there was also a massive snowstorm during this timeframe. The CME project management team, Metro’s customer service, and the customer communicated almost daily during this project, which was crucial to getting it completed. The clinic opened on time and the customer was extremely satisfied!
Massachusetts Ambulatory Surgery Center Passes DPH Inspection
Early in 2021, a Boston-area surgery center (ASC) expanded their footprint and added six new operating
rooms. The facility needed extra storage space, and a walk-through with Metro and CME account managers culminated in a CAD drawing that detailed several areas of high density, mobile, and stationary shelving solutions. The DPH inspection was scheduled for mid-May so that the new space could be certified for use. As time passed, Metro realized some of the items would not meet this inspection date. CME, Metro, and the customer met virtually to discuss options and possible solutions. With the customer’s blessing, Metro substituted some of the materials and carts to be able to meet the deadlines. The CME team was able to complete 80% of the installation in time for the inspection. The customer was ecstatic and the ORs were in use the next week.
Nashville MOB Maximizes Storage Space
In early 2021, a Nashville-area medical center was expanding their medical office building (MOB). At their current location they had big storage issues, as supplies were literally falling off shelves due to inadequate space. The new build-out was 61,500 sq. ft. and the storage space needed to be planned in advance to meet their needs. Metro, CME, the customer project manager, and the architect worked on the layout collaboratively and decided on top track shelving to maximize the storage space. The project included 201 shelving units with 1,058 shelves and 5,290 linear feet of shelving. The customer would never have supplies falling off the shelves in this new space! CME’s account manager worked with the customer and Metro early enough so that they could plan for extended lead-times on this project. The order was placed in September and all items will be delivered on-time to meet a February, 2022 need-by date.
Customized CAD drawing of top track shelving
Lessons Learned
The current pandemic continues to cripple the healthcare supply chain and will not resolve itself anytime soon. Healthcare systems need to be mindful when addressing new construction needs. Here are five things we recommend: ʯ Plan early and include distributors, manufacturers, and fellow team members in this early development stage. Get lead times well ahead of the project so that timelines can be met. ʯ Order early and work with partners who will over-communicate and give you visibility into where your products are at all times. ʯ Look at alternate products if lead-times move out too far. ʯ Find a partner who can help augment your depleted workforce including logistics and biomedical services. ʯ Be flexible and look for partners who are flexible also. These are tough times, and the best solutions can come from collaboration and being adaptable.
CME Corp is a full-service healthcare equipment and turn-key logistics company providing personalized support and service. With service centers nationwide, CME offers more than 2 million medical products from a total of over 2,000 manufacturers. CME is a healthcare system’s complete equipment solution by providing product selection, sales, warehousing, assembly, staging, direct-to-site delivery, installation, and biomedical services for all its equipment.
For over 80 years, Metro has been the world’s leading manufacturer of storage and transport equipment. From our innovative wire and polymer shelving lines to the revolutionary Starsys product line, and a broad range of healthcare cart solutions including the Lifeline emergency cart, Flexline procedure carts and Lionville series medication carts, Metro puts space to work in healthcare facilities of all sizes.
