Pandemic forces rapid switch to virtual visits

The COVID-19 pandemic has had wide-ranging effects on the practice of medicine. These include cancellations of in-office visits, surgery postponements or cancellations, social distancing in the office, and the explosion of telemedicine. As a result of the pandemic, the federal government has instituted emergency measures that lift restrictions on the use of telemedicine. This Urology Times® webinar, featuring experts in telemedicine, practice management, and coding and reimbursement, examines the impact this public health emergency has had on the practice-related aspects of urology and how urologists can prepare for the future once the emergency declaration is lifted. (To view the webinar in its entirety, see bit.ly/uttelemedwebinar.)

The panelists were moderator Jonathan Rubenstein, MD, chief compliance officer, Chesapeake Urology Associates, Towson, MD and clinical associate professor, department of surgery, University of Maryland School of Medicine, Baltimore; John Gore, MD, MS, professor of urology, University of Washington, Seattle; Aaron Spitz, MD, a urologist in private practice at Orange County Urology Associates, Laguna Hills, CA and assistant clinical professor of urology at the University of California, Irvine; and Eugene Rhee, MD, regional coordinating chief of urology at Kaiser Permanente Southern California.

In this segment, the panelists discuss how the COVID-19 pandemic led to rapid adoption of telemedicine visits at their practice.

Rubenstein: Let's talk about the public health emergency that we've gone through, which started affecting us all in February and really hit us in March. How has your practice evolved and changed, and how did your background lead you to where you are right now? Dr. Gore?

Gore: We instituted a rapid escalation of our telemedicine program across the department of urology in early March of this year. Around March 10th to March 12th, there was a recognition that for the safety of our patients and for the safety of our health care team, we needed to address our ability to care for patients, to have touch points with patients, but to not actually see them in person.

We went through our clinic schedules, and we changed everyone we could change to either a rescheduled visit or a telemedicine visit. We rapidly credentialed essentially the entire department of urology. Because we had had a grant to support our initial telemedicine program, we had actually pre-purchased a bunch of telemedicine equipment that we were able to pretty quickly deploy in our clinics. We don't have very fancy computers. We were able to upgrade those to have nice video capabilities and nice microphone capabilities. With credentialing and some scheduling changes, we were able to essentially turn over our entire clinic to telemedicine.

There are still some patients who do need to come in, patients who need some surveillance visits, but for the most part, we have tried to convert almost 100% of our clinic into a telemedicine clinic.

Rubenstein: Dr. Spitz, how did your practice change?

Spitz: Our practice, very much like Dr. Gore's, changed rapidly over the course of just a few days in early to mid-March. The majority of the partners in my practice have adopted a policy of limiting patient visits to only those that are urgent, as well as procedures and surgeries. The decision to limit surgeries is something that has been made at a higher order level amongst all the hospitals and surgery centers in our community. But nonetheless, we were all on board with that because we felt it was imperative to do our best to flatten the curve by minimizing the interactions of patients with each other and with our staff, and by minimizing the interactions of our staff with each other.

Given that we're in a private practice, we can be rather nimble with the configuration of how we incorporate telemedicine. There is no particular credentialing that is required, and because of my previous experience with telemedicine and because we had a medical platform up and running in our practice, which anecdotally only I was ever using, even though it was available for the entire practice, that was ready to go on day one.

With the increased surge of demand on the platform, it was rather glitchy for a few days, but fortunately, the platform was able to increase its infrastructure, and now it runs just fine. But even if we hadn't had the platform in place, the rapid changes in the requirements and regulations, including the HIPAA restriction being lifted, enabled any or all of us to use our cell phones or our laptops with platforms such as FaceTime or Skype.

The rollout was really not very hindered by hardware considerations. What was probably the most significant issue was just the novelty of it. I was able to reassure my partners how easy or straightforward it could be, and they could trust me in that reassurance because I had been doing it for many years and I had seen over 1200 patients telemedically in our practice through the platform that we were about to use.

I found that the engagement with telemedicine amongst my partners who were completely naive to using it was remarkably fast. Within a day or two, my partners were seeing up to 20 patients in a single day. Now, our practice is very busy and those same partners might see 40 to 50 patients in person in a single day, but still, to engage at that level was remarkable. Then again, it wasn't because I knew from my experience with telemedicine that it's a very straightforward process. I think that that's what so many doctors, whether they’re urologists or other specialists, are waking up to around the country, that this is rather straightforward and the patients themselves are also recognizing how straightforward and easy it is.

I remember there was a bias in telemedicine in general, and certainly I held this bias, that older patients in the Medicare population probably wouldn't be too happy with telemedicine and that this is really something for the younger generation, who is tech savvy. I'm finding nothing but f amongst my Medicare-age patients for whom I'm performing telemedicine encounters.

Rubenstein: Dr. Rhee, how about you?

Rhee: Dr. Spitz mentioned the regulatory hurdles and reimbursement hurdles as well as licensing and medical-legal aspects. These are things that were barriers to entry in regard to telemedicine. We were confident at Kaiser, where we already knew that the satisfaction was there, that the quality was sustained. The issue here is that COVID-19 brings with it the safety issues in regard to both providers and our patients, and as well, understanding how we can still create capacity without just halting our practices.

What's different for us is that the ecosystem is already embedded obviously. Because of that, our own local regulatory and IT issues were already there; they were prepared for something like this. I think the issue now is scalability. I think that our job in our different practices is to convey the amount of work that we're doing on the telemedicine side and to show government, other regulatory agencies, and payers that this actually is a viable alternative model of health care delivery.

It's extremely important to understand that January 31 was when the public health emergency was declared. March was when things really started to get going. Through two signatures by the swipe of a pen, the amazing major legislative and regulatory milestones have been lifted, albeit, maybe temporarily, but now the drivers for all of this work are different. The physicians are driving this, the patients are driving this, and actually in essence, health plans and health care networks are driving this because of the backlog.

What we're doing now is preparing for the future. What does the future look like? How do we look at a telephone visit or a video visit, and how does that translate into future visits?

A really important aspect to this is to understand the pending suppressed demand, because I don't think that diagnostic imaging and other visits have been continuing on a regular basis. How many of these patients are sitting out there that really we need to move forward quickly on, because I believe that that's the next surge. This is really the surge that I think our physicians who are on this webinar are really concerned about.