By Rebekah Meola

Dr. Gregory Buford is a Board Certified plastic surgeon based in Denver, Colorado. In his private practice, he’s been doing virtual consultations for several years. “We work with a lot of patients in the mountains around here. They may be a couple of hours away. We also have patients from across the country and who fly in from outside the country,” he says. For many of these patients, Dr. Bufors conducts their first visit, and follow-up visits remotely. “I was using this long before the pandemic. However, once Colorado asked us to stay home, I realized I still needed to communicate with my patients, and I still needed to get the word out about my practice, so I ramped up my virtual consult service offering. I built out a larger presence for virtual consults on my website and promoted the service on social media. Since then, we've seen a definite uptick in demand for the virtual consult.”

Meeting patients' needs in a time of crisis: surprises and a warm heart

In April 2020, Doximity.com conducted a national survey asking physicians if they increased their use of telemedicine technologies in their clinical practices in response to COVID-19. Of those who responded, 52.7 percent said they did increase their use of telemedicine, 19.1 percent said they had not, and 28.1 percent said they had not, but we're moving towards it.

Dr. Alexander W. Sobel is a cosmetic surgeon and immediate past president of the American Board of Cosmetic Surgery based out of the Seattle, Washington area, who describes himself as the “antithesis” of someone who would get involved in virtual visits with patients. “I’m kind of an old-school doc who believes that if you can't convey something in a conversation that's spoken words and you're not doing a good enough job. I take care of people across the country, even internationally; we take care of them at our practice. We've had limited telehealth experience, but it's always been in a framework of when you come to our office, this is how it's going to be. But I've realized that's not only impossible at the moment, but it's not meeting the needs of the public; the public needs something different. Patients deserve a forum for their questions and their interests. What I am learning from this is that we need to adapt,” he says.

Of his first significant foray into telemedicine, Dr. Sobel has found himself surprised: “These telehealth conversations have been going in a direction that I didn't necessarily expect. I thought these inquiries would be with people who were just perusing options and getting information. But the amount of humanity that I've found and returned in these visits is just striking. People are so glad to be able to reach out and have a question answered.”

Besides meeting patient needs, Dr. Sobel finds himself meeting his own needs at this time as well. “For my part, I'm thrilled that I have somebody to apply my trade to. I've studied for so long and served so many people, and I realize at a time like this, how much I miss it,” he says.

Dr. Sobel has also reached out to his existing patients. “What I've tried to do, and I've charged my staff with doing whenever we have the opportunity, is just to pick up the phone and ask our patients how are you doing? Is there anything we could do to help you? Just opening the question has created some really interesting conversations. I expected them to be very circumspect, but the interactions have been very touching. The individuals had been very grateful for the accommodations to be able to ask their questions. The interactions have been deeper than I often see in the office quite honestly.

“I think the currency that is being exchanged in these testing times is you have a patient and a physician that are willing to carve out a special space for each other in somewhat of an awkward, unusual environment to make a connection. I think it's something special and something to look forward to, not to be afraid of.”

Dr. Tony Das is an interventional cardiologist in Dallas, Texas, and a nationally-recognized expert in complex coronary and peripheral vascular interventional procedures. He agrees, “It's imperative that we continue communication with our patients now.” Dr. Das is already an expert in the field of digital health. In November 2019, he founded Connected Cardiovascular Care Associates -- the first US private cardiovascular practice dedicated to incorporating digital health with remote physiologic monitoring of chronic cardiovascular conditions for patients. Still, telehealth in the time of COVID-19 has held some surprises for him. “One of the things that I have found interesting and heartwarming is that when we've reached out to patients who only had testing scheduled without an office visit and said, ‘Hey, we just wanted to touch base with you to make sure you are doing OK. Would you like to schedule a telemedicine visit to just touch base?’ The overwhelming response is, ‘Absolutely; we'd love to catch up.’ And in fact, many of these patients have real medical problems they relayed such as high blood pressure or new cardiac symptoms that they would have ignored if we hadn't reached out. This may explain the massive reduction in emergent heart attacks in emergency rooms. Patients are not just communicating the way they previously had. We originally thought maybe this would be a burden on patients to have to communicate when all they were coming in for was a follow-up for a test or something like that. But the response has been almost a hundred percent that they want us to communicate with them and that gives them a sense that they're cared for,” he says.

“I would tell anyone who's even considering telehealth, this is not the time to disengage with your patients. I think it's a time to totally engage with them, even if it's for a quick catch up, just to let them know that you're there. We've found many, many patients who would have otherwise not followed up for an office visit who, when we get them on the phone, we say, ‘Okay, well, you know, you have a way of checking your blood pressure. What is it? Oh, it's 200 over 100’ or, ‘you know, I just had an episode last night where I had weakness and slurred speech on one side, or by the way, my left leg is feeling cold.’

“We are hearing during televisits things that patients would have ignored that are critical problems that need to be addressed and evaluated that would have otherwise led to an emergency room visit. So I think the key here is that we're picking up disease and, and suffering by just communicating with the patients, which is sort of the imperative right now.”

Getting started with telemedicine: what you need to know

Telehealth is an umbrella term for the delivery of health services and information using electronic methods. The term is sometimes used interchangeably with digital health. Telehealth, as many knows, was started in rural America, where patients had less access to a wide array of medical care. While telehealth encompasses telemedicine, research, disaster response, and administration, the term telemedicine relates to the delivery of remote clinical services. There are several methods for delivering clinical services remotely, including live or “synchronous” methods, where patient and physician speak in real-time through video conferencing tools; store and forward delivery method, where information is passed between providers or patient and provider for each to review in their own time; and lastly digital monitoring which is the use of digital technologies to collect health data from individuals in one location and electronically transmit that information to physicians and health care providers in a different location for assessment and recommendations. A related term here is mHealth, which is the use of mobile devices such as watches and smartphones in the collection of such data.

Telemedicine has been around for a long time. But the big difference since mid-March is that the rules of where the site has to originate from no longer apply, at least temporarily. It used to be that the patient had to be either in another physician's office or in a rural area where they didn't have access or in another clinic.

In an emergency declaration made March 17, 2020, the Centers for Medicare & Medicaid Services (CMS) said it would pay providers to care for Medicare beneficiaries for office, hospital, and other visits furnished via telehealth anywhere in the country and including a patient's place of residence.

CMS also loosened the rules for HIPAA compliance. Before, where physicians could only use HIPAA compliant tools in the delivery of health services, now temporarily, CMS is allowing physicians also to use non-compliant tools such as Zoom, Skype, Google Duo, and FaceTime. (both Zoom and Skype can be made HIPAA compliant through the use of what is known as a Business Associate Agreement (BAA). However, at this time, physicians are permitted to use these tools even without a BAA in place).

Physicians will find no shortage of video conferencing tools. In addition to the applications mentioned above, frequently, most electronic health record (EHR) programs, contain tools dedicated to the use of telemedicine, Dr. Das points out. “They aren't turned on and for many systems, they haven't been needed until more recently,” he says. “The system that we use-- called eClinical Works-- has a module for that. Others also have modules that have been used for a small fraction of patients over the last several years, until the recent changes in CMS guidelines.”

Dr. Buford says that when it comes down to it, you need to get a platform that's not only high quality but also that that's easy to use for the consumer, “You need to give your patients few hoops to jump through and the fewest number of steps as possible to make the process seamless.”

Dr. Buford currently uses Zoom, a prevalent video conferencing platform. Dr. Buford mentions at the beginning of his plastic surgery consults that this form may not be HIPAA compliant. He explains, “We don't have patients undress, we have patients send us photos before the consult if it's going to involve something like the breast or what have you so that I can review those photos before the consult. I do that less for HIPAA compliance and more just for the comfort of the patient.”

Even if you're using a platform that's HIPAA compliant, are you meeting the duty that you're obligated to for your patients with virtual care? That’s a question Dr. Sobel asks. “I think all of us are trying to look both inside and outside for answers to that question as fast as possible,” he says.

“I've got two young kids in different schools. It's the teachers who initially raced to adapt to distance learning at the beginning of COVID-19. And now we're virtual, and I've watched the teachers and students evolve from, ‘Okay, now we're virtual to now we need to learn how these kids need to learn in this environment.’ I feel like I'm experiencing the same thing with my patients. I don't think it's a waste of time to try to figure this out together. Patients and providers, we don't have to be perfect the first time.”

Beyond virtual consultations

According to Dr. Das, there are over 120 telehealth companies that are out there. “You have to try to get, not just the communication platform in place, but also the audiovisual, and then add pieces of the examination if possible, into the visit to make it meaningful. And that's what we're working on now is trying to identify physiologic things that we would otherwise check in the office and try to do them through a remote system. That's part of what our challenge is now.”

Telemedicine landscape for vascular specialists

There are “digital health” tools for vascular specialists today, and “they're evolving in their overall complexity and in how unique they are to either arterial or venous disease,” says Dr. Das. “Every physiologic parameter you can imagine has a surrogate in telemedicine. If I want to know someone’s heart rate or heart rhythm, I can listen to someone with a stethoscope, or I can give them a wearable that might be able to do that. If I'm talking about arterial and venous disease, there are things that we do in the office, such as arterial Dopplers and venous duplexes. But there are also telemedicine technologies that are out there that are digital. For instance, there's a pair of socks that you can put on somebody that can tell if there are hot spots in their foot, and you can identify diabetic foot ulcers before they occur.

“There are other things that look at venous insufficiency by way of volume flow in the legs that are in development. Some of these digital projects are still in development. But ultimately, there will be a digital equivalent of the thing that you do in the office that patients will be able to utilize to identify either venous or arterial insufficiency or other cardiac conditions.

There are already telemedicine platforms for podiatry. Wound care technologies exist, such as Carepics and projects like that.

There's going to be a whole strategy of what's the digital equivalent of what we're doing in the office, not only for cardiovascular disease but for arterial, venous, and really every other specialty that you can think of.”

Benefits of telemedicine

One of the most recognized benefits of the remote delivery of medical services is the time-saving aspect for patients as well as the saving of travel costs.

“With everyone working, often patients say, ‘I'm working during the day. I don't get off until 4:30. Do you have an after hour appointments?’ If you have a busy executive and they're halfway across town, if they can consult with you over the phone or the internet, they don't have to get in their car. They don't have to go anywhere. They don't have to worry about traffic. They don't have to worry about how long their wait will be. They're right there. In his plastic surgery practice, Dr. Buford says virtual consults are more focused, more condensed, consults: “I already have the information beforehand, so I've done a lot of the processing before they even get in there. In terms of using your time wisely, I think they're much more time-effective than an in-person consultation.”

Virtual consults also lend themselves to greater flexibility for patients. Dr. Buford recalls a virtual consultation with a patient about ten days out of her breast augmentation. “Her husband is in the military back East, and she had to travel. We did all the follow-up just by digital, and it went great. She knows that she can contact me now, give me a ring, email me any questions. It makes it a lot easier for those patients,” he says.

Considering telemedicine beyond COVID-19

“Once COVID-19 passes, we'll find that virtual consults are not a fad; they're here to stay,” says Dr. Buford. “Those practices that have incorporated the use of virtual consults will prosper dramatically more than those practices that have not.”

It’s not going to replace in-person consultations completely. Certain consult virtual visits are appropriate for, and other times, the patient needs more reassurance, and they may not be able to get that reassurance online. But everybody's different, and millennials are more focused on digital means. They are already on all the platforms, and they know them well. Older patients are learning them, as well.”

Tips for starting with telemedicine

When Dr. Buford got started with telehealth, he wanted to jump straight in and speed things up. To do this, he identified a couple of his peers who had been doing this for a while. “I reached out to them and said, ‘How'd you get this going? What did you find were the pitfalls and you, what mistakes did you make?’ I encourage anyone who is looking to get into this to identify who they think are the real leaders in this area. You'd be surprised. Of the people that I reached out to, I had pushback from no one; no one said, “That's my information.’ Every single person I reached out to was more than happy to share their tips. We're all very busy, but we all love to educate. We all love to pass along what we found is helpful.

“I say the most important thing, though, is in the words of Nike, just do it, and understand that you're going to make mistakes; you're probably going to change how you do your consults over time. I always say that one of the worst things when it comes to moving forward is the paralysis of analysis. It's overthinking something so much that you never move anywhere.”

According to Dr. Sobel, “there's so much to be learned about telehealth in terms of best practices, what's acceptable ethics and otherwise. But I think that it's okay that the docs and the patients are just kind of bumbling through this; to start, let's just reach out and have a conversation.

For those who are ready to get started with telehealth, Dr. Das advises, “Start with something simple, go to your electronic health record and see if there's a telemedicine option there. Ask your administrators if there is, and if there's not, then there are free versions out there of things that can be incorporated, and you can use them in conjunction with what you’re already using for electric health records.

Doxy.me is a very well established platform. I've been using it for my wife's aesthetic business for a couple of years, and now when COVID-19 started, we were able just to turn it on quickly. There are plenty of platforms out there that are either free or very inexpensive; just start with one and start using it.”

For more on cardiology during COVID-19, see Dr. Tony Das and colleagues in this Webinar from Texas Heart Institute