Telehealth’s evolution continues as COVID-19 restrictions loosen

Telehealth is not new in dermatology, but with COVID-19 leading to an unprecedented shutdown of most of the country earlier this year, it has been thrust to the forefront of practices, leading to a large learning curve for both providers and patients.

“The COVID-19 pandemic has kind of forced our hand to accelerate the use of telehealth, or ‘telederm’ as we nickname it in dermatology,” Dawn Marie R. Davis, MD, professor of dermatology and pediatrics at Mayo Clinic in Rochester, Minnesota, said. “It’s a dyad, and both parties, the provider or organization and the patients, have to be comfortable with using telehealth platforms.”

A July survey from Harmony Healthcare of more than 2,000 Americans found the majority to believe telehealth provides not only safety in this time of a global medical crisis, but also convenience for those seeking care.

Forty-nine percent of respondents said they had used telehealth before COVID-19, with 67% using it since COVID-19.

The top reason for using telehealth was convenience, cited by 63% of respondents. Safety and avoiding virus exposure were cited by 59% and flexibility by 46%.

Synchronous vs. asynchronous

In dermatology, telehealth’s genesis involved using asynchronous programs that allow patients to send photographs via an online portal to be evaluated by a physician. This is also called the “store-and-forward” method, according to Davis. It has evolved to include telephone calls and, most recently, live video feed appointments.

“Based on your geographic location, access, demand and the types of patients that you care for, a lot of providers are now doing a form of telemedicine every day they are in practice,” Davis said.

Joseph English III, MD, medical director and teledermatology director at University of Pittsburgh Medical Center, has been using the asynchronous model since 2008. When the COVID-19 pandemic began, the center continued that program but quickly added a synchronous platform to allow video visits.

English and his colleagues recently completed a study looking at how their telehealth programs evolved from the onset of the pandemic to May 20 when they began seeing some patients in the office again.

“Initially, we had an increase in asynchronous visits, and then when video visits started, they took over,” he said. “At the end of that study, we concluded the best combo is a hybrid teledermatology, especially for complicated psoriasis patients on biologics.”

The hybrid model has patients send in photographs for review and participate in live video visits.

“It’s good to have them live so we can interact with them, but they need to send digital images so we can evaluate the skin,” English said. “Video visits aren’t that great for making a diagnosis because every phone is different, and you can’t always get the acuity you need in imaging through a video app.”

Technological difficulties

While a video call has many benefits, it can be difficult to see anomalies on the skin, especially if they are small. However, there can be similar problems in digital photographs.

“Oftentimes, it’s difficult to assess because of lighting effects, shadow effects, the picture may not be in focus, or the rash or lesion is too close or too far away,” Davis said. “What’s impactful and important for the dyad to function is that both sides have the appropriate infrastructure and technology to make it happen.”

The quality of images and the proper bandwidth for video visits are the main limitations to successfully integrating telehealth into a practice.

“A frustration that has arisen with general telemedicine is that glitches can happen with technology. This can cause a disruption or delay of minutes to hours,” Davis said. “As a society, we are getting much more comfortable with technology. We are becoming more nimble in general as a population, but there are still certain demographics in the population who are not comfortable with technology, and that can be a challenge.”

Turning a 3D specialty into a 2D encounter

Because many restrictions have begun to be lifted throughout the country and in-person visits are permitted again, the question arises as to when telehealth visits are appropriate and when a patient should be brought into the office.

Providers must judge carefully to determine when visits can be completed remotely.

“In the world of dermatology, there’s a lot of touch involved. There’s visualization using devices in the office. There are certain in-office tests and skin scraping to help us make a diagnosis,” Joe A. Gorelick, MSN, FNP-C, founder of the Dermatology Educational Foundation and a dermatology nurse practitioner at California Skin Institute, said. “The big obstacle clinically is taking a 3D specialty and turning it into a 2D encounter.”

When it comes to psoriasis treatment, however, telehealth’s convenience factor is a big draw for follow-up and monitoring visits.

“Where telehealth is going to be most effective is going to be for return patients and drug monitoring,” Adam J. Friedman, MD, FAAD, professor and interim chair of dermatology at George Washington University, said. “I think psoriasis is a very good example of a disease state that is amenable to telehealth. You can use screening tools to screen for psoriatic arthritis. You can look at the nails. I think inflammatory skin diseases are a very good example of something for which telehealth works, especially in someone who has an established diagnosis.”

While skin cancer and unusual growths are difficult to treat via telehealth, psoriasis can be seen, monitored and cared for via video visits.

“If you’re on a systemic medicine for your psoriasis and you normally go through a med monitoring protocol and have a standard follow-up, that is a very pleasant experience over telemedicine,” Davis said.

Billing and coding

Billing telemedicine visits has historically been a major obstacle. Previously there were few reimbursement codes for most forms of telehealth, but in March, when the pandemic shut down many practices, exceptions were made to allow for it.

CMS broadened access to telehealth with a temporary emergency waiver allowing payment for services conducted electronically during the pandemic, and many insurance companies have followed suit.

“The limitation with telemedicine wasn’t that we didn’t know how to use it or that it wasn’t part of our lexicon. The limitation was that we couldn’t do it because it wasn’t reimbursable,” Friedman said. “When the federal waivers went into effect and all of a sudden we have a handy little modifier on our billing, we could now do telemedicine for pretty much everyone.”

The American Academy of Dermatology has since released guidelines on telemedicine that explain the CMS guidance and inform dermatologists of the best ways to proceed with telehealth in their practices. The academy’s teledermatology toolkit includes a downloadable flowchart to keep track of the correct codes, as well as a downloadable coding guide.

While the waivers have been extended to the end of 2020, it is still a question if telehealth coding will be as easily accessible as the pandemic becomes less severe.

“The biggest issues are, ‘Will these visits be reimbursed? Will we lose money doing telehealth?’ and we just don’t know yet,” Friedman asked.

The continuation of telehealth codes and reimbursement will be the only way to provide the option for patients.

“It’s imperative that insurance companies cover these services and understand the level of care is equivalent, and therefore efforts should be recognized in billing and coding,” Davis said. “The local, state and federal governments have been very flexible during the time of the pandemic because they were able to focus on ensuring patients got care when needed in a way that was safe for both the patient and the provider. As state and federal laws adapt to medical care, insurance companies will need to be mindful of that so they can align with legal statutes.”

Patient satisfaction

The first priority throughout the pandemic has been to care for patients in a safe and secure manner, but telehealth has also proven to be a satisfying experience for most patients.

“The patients actually love it,” Gorelick said. “They are used to coming into our office and seeing us in our home, if you will, but now they are opening up their devices in their own home and sharing that with us a bit.”

The ability for patients to reduce travel time, child and/or elder care needs and avoid taking time off from work or school has added to telehealth’s benefits.

“We weren’t exactly sure how patient experience and satisfaction would be with telemedicine, but I have found anecdotally in my patient population that it’s a very pleasing thing for them,” Davis said.

Future of telehealth

Telehealth will continue to evolve to fit patients’ needs and safety requirements, but what will happen when there is no longer a pandemic forcing telehealth’s necessity?

Friedman believes that more studies on telehealth’s popularity and benefits are needed to ensure coding is available and telehealth can continue.

“It always comes down to meaningful use. If we can show that certain areas of dermatology will actually save money and allow for better outcomes, I think we can probably keep some of it,” he said. “I’m hopeful that our community can band together and generate data that show in the right circumstance telemedicine is not inferior to a live visit, can actually improve patient satisfaction and outcomes, and also save money. But we need that data to prove that.”

In addition, as technology continues to improve and the population becomes more adept at using it, telehealth will have to be further involved in patient care.

“I believe that telehealth, of all modalities, will increase over time due to convenience, accessibility and familiarity,” Davis said.

References:

American Academy of Dermatology teledermatology guidance. https://www.aad.org/member/practice/telederm/toolkit.

Harmony Healthcare IT survey. https://www.harmonyhit.com/survey-americans-plan-to-use-telehealth-after-covid-19.

For more information:

Dawn Marie R. Davis, MD, can be reached at Mayo Clinic Arizona campus, 200 First St. SW, Rochester, MN; email: davis.dawnmarie@mayo.edu.

Joseph English III, MD, can be reached at University of Pittsburgh Department of Dermatology, 9000 Brooktree Road, Suite 200, Wexford, PA 15090; email: engljc@upmc.edu.

Joe A. Gorelick, MSN, FNP-C, can be reached at California Skin Institute, 2420 Samaritan Drive, San Jose, CA 95124; email: jgorelick1@me.com.

Adam J. Friedman, MD, FAAD, can be reached at George Washington School of Medicine, and Health Sciences, 2300 Eye Street, NW, Washington, DC 20037; email: ajfriedman@mfa.gwu.edu.