The following paper was written by Rifat Latifi, MD, FACS and published in the Bulletin of the American College of Surgeons.
Telemedicine has the potential to provide rapid, safe, and high-quality care, but these virtual clinical services did not take center stage until the coronavirus 2019 (COVID-19) pandemic. In fact, the pandemic may well be remembered as the rebirth of telemedicine and telehealth. Every condition that a health care professional can see in a patient physically can be seen through telepresence, if not better. The perioperative work-up and surgical decision making can be done through telemedicine, as well as postoperative visits.
Although we all enjoy and value seeing our patients face-to-face, virtual interactions can be similar to physical visits, unless serious problems and complex interventions need to be done immediately and onsite. Perhaps the benefit of the COVID-19 pandemic will be the creation of a new virtual medical world. The main reason telemedicine has grown in popularity and will continue to do so in the future is due to how this technology benefits patients while simultaneously minimizing patient, provider, and community exposure to the virus. Patients are more frequently requesting telemedicine visits instead of meeting face-to-face, both for initial and follow-up visits.
Although in recent years telemedicine has become more acceptable, the health care community was sometimes reluctant to embrace telehealth services, despite its potential to provide patients with access to rapid, safe, and high-quality care. This mindset has evolved with the COVID-19 pandemic.
COVID-19 is a respiratory infectious disease caused by a novel strain of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first case of the unknown pneumonia was reported in Wuhan City, Hubei Province of China, on December 31, 2019.1 After 71 days, on March 11, the World Health Organization (WHO) declared COVID-19 a pandemic; it is the first pandemic in written history caused by a coronavirus. The first case in the U.S. was reported January 11, 2020,2 and as of August 8, more than 19 million had been confirmed worldwide; more than 716,000 people have died of COVID-19 in 216 countries, areas, or territories, according to the WHO.1
The health care community was not prepared to meet the challenges of the COVID-19 pandemic. The pandemic caused major morbidity and mortality, as well as high risks for economic, social, and political disruption, despite specific and more sophisticated standards for detecting, reporting, and responding to outbreaks.3-5
The ongoing pandemic already has changed the world significantly, unlike any public health crisis since the 1918 Spanish flu pandemic, which affected 500 million people, or almost one-third of the world’s population of 1.8 billion at that time.6 In fact, the Spanish flu is estimated to have killed at least 50 million people worldwide and 675,000 people in the U.S. alone.7 The mortality rate of the Spanish flu pandemic was especially high in the younger population, with an age range between 15 and 34 years.8
Because of COVID-19, the medical community has come to realize that telemedicine is, in fact, applicable, desirable, acceptable, and a much sought-after means of providing health care service—first by our patients and then by the hospital community at large.9
Prominent health care experts and sociologists predict the ongoing COVID-19 pandemic is likely to create sustained and responsible change in human behavior and attitudes, which may lead patients (especially people with chronic conditions) to prefer telemedicine to routine in-person hospital and office visits.10 Nonetheless, implementation of telemedicine should be evidence-based, performance and quality control should be measured, and continuity of care ensured.11 Moreover, for telemedicine to gain acceptance, it needs to be tested and used not only during the pandemic but on a continuing daily basis.
What does this transformation mean for surgery?
Everything that a health care provider can assess visually in a patient during a preoperative consultation can be seen via a telemedicine-based interaction. In fact, the entire perioperative care process can be done virtually.12
Although a number of enthusiastic surgeons and physicians have been teaching and practicing telemedicine around the world, only recently have these virtual visits become the new normal to such a remarkable degree. Other outbreaks such as SARS-CoV (Severe Acute Respiratory Syndrome–associated coronavirus), MERS-CoV (Middle East respiratory syndrome coronavirus), or other public health emergencies of international concern related to Ebola and Zika viruses have brought telemedicine front and center.13 However, because these diseases were contained comparatively quickly, the expanded practice of telemedicine was relatively short-lived.
COVID-19, on the other hand, has transformed the way health care is delivered around the world and telemedicine has emerged as a critical technology to bring care to patients while attempting to reduce the transmission of COVID-19 among patients, families, and clinicians.14
Challenges to broader use of telemedicine include the need to frequently adjust rapidly evolving administrative requirements, to meet the challenges associated with communication technology, and to coordinate the needs of multiple stakeholders while maintaining high-quality, pre-pandemic medical care.15
Usefulness with aging, disabilities, and mental health
The use of telehealth in the era of COVID-19 has been reported in the elderly Chinese population, which in 2017 numbered more than 241 million. China has the largest aging population globally. Many of these individuals live alone with little social support. Of 241 million elderly Chinese, more than 30 million people are older than 80 years of age, and more than 40 million required long-term care resulting from disabilities.16 Use of telemedicine and telehealth services in these patients has been documented and should become part of overall health care services.16-22 The implications of telemedicine in mental health care have been a natural extension of telepsychiatry.23,24 Telemedicine and other technologies also have been used to prevent hospitalization, amputation, and mortality.25
This technology also may be used during global emergencies.26 Avoidance of in-person clinic and emergency department visits further add to the urgent societal goal of maintaining social distance to contain the COVID-19 pandemic.27
Resources for surgeons seeking to use telemedicine
In the U.S., the federal government has offered financial incentives for health care practices that adopt telemedicine. More specifically, on March 30 the Centers for Medicare & Medicaid Services (CMS) revised, on an interim basis, requirements for the use of telehealth during the COVID-19 national public health emergency (PHE), retroactively effective to March 1, 2020.
CMS released a list of Merit-based Incentive Payment System (MIPS) quality measures that include telehealth for the 2020 MIPS performance year. The resource provides guidance for eligible clinicians, groups, and virtual groups who plan to report these measures to achieve a score in the quality performance category of MIPS. CMS notes that there may be instances where the quality action cannot be completed during a telehealth encounter. In these cases, CMS explains that it is the MIPS clinician’s responsibility to ensure they meet all other requirements within the measure specification, including other quality actions that cannot be completed by telehealth. The list of clinical quality measures are listed within the 2020 Quality Measures List with Telehealth Guidance.28
CMS also shared telehealth guidance related to electronic clinical quality measures (eCQMs) in the Electronic Clinical Quality Improvement Resource Center,29 and more information is listed in the document titled “Telehealth Guidance for eCQMs for Eligible Professionals/Eligible Clinicians for 2020 Quality Reporting.”28 Those who submit quality measures via the CMS Web Interface should refer to the CMS Web Interface measure specifications and supporting documentation for detailed information regarding the use of telehealth within this collection type found in the Quality Payment Program Resource Library.30 Additional questions can be directed to QualityDC@facs.org.
The American College of Surgeons (ACS) provides several resources to help surgeons navigate CMS’ evolving guidance on telehealth, and has published information on its website to help surgeons navigate the evolving opportunities that are available to surgeons and their practices.31 In addition, the ACS Division of Advocacy and Health Policy hosted a webinar this summer highlighting the experiences of Fellows who have integrated and operationalized telehealth in their surgical practices during the COVID-19 pandemic.
A recent Journal of the American College of Surgeons article described the process of developing and integrating telemedicine capability into a surgical practice, providing a comprehensive guide on how to rapidly integrate telemedicine into practice during a pandemic.32 The authors built a toolkit that comprises what they identified as eight essential components to successful implementation of a telemedicine platform, as follows:32
- Provider and staff training
- Patient education
- An existing electronic medical record system
- Patient and provider investment in hardware
- Billing and coding integration
- Information technology support
- Audiovisual platforms
- Patient and caregiver participation
Many health care providers have been affected by COVID-19 all around the world; some have even died because of this pandemic. Telemedicine can help protect health care professionals at all levels of care and training. Moreover, telehealth has been shown to reduce burnout during these dangerous and stress-filled times.33
Telemedicine has consistently shown to be effective in extreme conditions, including natural or man-made crises and disasters, people living in remote areas, or countries with limited resources. The health care professionals on the front lines in the fight against the COVID-19 pandemic also are the victims of an extreme circumstance.33 The biggest advantage of telemedicine in this crisis is its ability to continue providing health care services at a safe physical distance.
William C. Welch, MD, FACS, FAANS, FICS, FANOS, Chair, ACS Advisory Council for Neurological Surgery, described his recent experience with using telemedicine. “The 30 patients I evaluated recently in the office via telemedicine were in the comfort of their homes, usually accompanied by their spouse, and not terribly angry with my tardiness. They came from five different states and were thrilled to be able to receive an evaluation without the inconvenience of intra- and interstate travel. The history and radiographic reviews that I obtained were similar to what I collect during in-person visits. The physical examination was slightly more limited than an in-person consultation,” he wrote in a recent issue of the ACS Bulletin Brief.34
Dr. Welch added that because telehealth allows patients to receive highly specialized evaluations in a convenient fashion, the ACS Advisory Council for Neurosurgery strongly supports the continued option for patients to have access to telemedicine consultations with their specialists of choice and supports the College’s efforts to this effect.
It is safe to say health care in the post-COVID-19 era will be much different than it was before the pandemic struck. Heightened use of telemedicine services will be one of the more notable and beneficial changes.
- World Health Organization. WHO characterizes COVID-19 as a pandemic. Available at: www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. Accessed August 8, 2020.
- Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Cases in U.S. Available at: www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed March 29, 2020.
- World Health Organization. International Health Regulations 2005. 2nd Ed. Geneva, Switzerland: World Health Organization Press; 2008.
- Katz R, Seifman R. Opportunities to finance pandemic preparedness. Lancet Glob Health. 2016;4(11):e782-e783.
- Wolicki SB, Nuzzo JB, Blazes DL, et al. Public health surveillance: At the core of the global health security agenda. Health Secur. 2016;14(3):185-188.
- Centers for Disease Control and Prevention. 1918 Pandemic (H1N1 virus). Available at: www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html. Accessed April 13, 2020.
- Jester B, Uyeki TM, Jernigan DB, et al. Historical and clinical aspects of the 1918 H1N1 pandemic in the United States. Virology. 2019;527(15):32-37.
- Jester B, Uyeki T, Jernigan D. Readiness for responding to a severe pandemic 100 years after 1918. Am J Epidemiol. 2018;187(12):2596-2602.
- Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382:1679-1681.
- Froes F. And now for something completely different: From 2019-nCoV and COVID-19 to 2020-nMan. Pulmonology. 2020;26(2):114-115.
- Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
- Duffy S, Lee TH. In-person health care as option B. N Engl J Med. 2018;378:104-106.
- Ohannessian R, Duong TA, Odone A. Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: A call to action. JMIR Public Health Surveill. 2020;6(2):e18810.
- Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. J Pain Symptom Manage. 2020;S0885-3924(20):30170-30176.
- Reeves J, Hollandsworth HM, Torriani FJ, et al. Rapid response to COVID-19: Health informatics support for outbreak management in an academic health system. J Am Med Inform Assoc. March 24, 2020 [Epub ahead of print].
- Yang Y, Li W, Zhang Q, et al. Mental health services for older adults in China during the COVID-19 outbreak. February 19, 2020 [Epub ahead of print]. Lancet Psychiatry.
- Villani A, Scalvenzi M, Fabbrocini G. Teledermatology: A useful tool to fight COVID-19. J Dermatolog Treat. 2020;31(4):325.
- Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. J Pain Symptom Manage. 2020;60(1):e12-e14.
- Connor MJ, Winkler M, Miah S. COVID-19 pandemic—is virtual urology clinic the answer to keeping the cancer pathway moving? BJU Int. 2020;125(6):E3-E4.
- Gachabayov M, Dong XD, Latifi R, et al. Considerations on colorectal cancer care in a COVID-19 pandemic epicenter. Surg Technol Int. 2020;36:148-149.
- Greenhalgh T, Koh GCH, Car J. Covid-19: A remote assessment in primary care. BMJ. March 25, 2020. Available at: www.bmj.com/content/bmj/368/bmj.m1182.full.pdf. Accessed August 14, 2020.
- Greenhalgh T, Wherton J, Shaw S, et al. Video consultations for Covid-19. BMJ. March 12, 2020. Available at: www.bmj.com/content/bmj/368/bmj.m998.full.pdf. Accessed August 14, 2020.
- Portnoy J, Waller M, Elliott T. Telemedicine in the era of COVID-19. J Allergy Clin Immunol Pract. 2020;8(5):1489-1491.
- Huang S, Xiao Y, Yan L, et al. Implications for online management: Two cases with COVID-19. Telemed J E Health. 2020;26(4):487-494.
- Rogers LC, Lavery LA, Joseph WS, et al. All feet on deck—the role of podiatry during the COVID-19 pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc. March 25, 2020 [Epub ahead of print]. Available at: https://meridian.allenpress.com/japma/article/doi/10.7547/20-051/436248/All-Feet-On-Deck-The-Role-of-Podiatry-During-the. Accessed August 17, 2020.
- Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020;26(5):309-313.
- Szperka CL, Ailani J, Barmherzig R, et al. Migraine care in the era of COVID-19: Clinical pearls and plea to insurers. Headache. 2020;60(5):833-842.
- eCQI Resource Center. Telehealth guidance for electronic clinical quality measures (eCQMs) for eligible professional/eligible clinician 2020 quality reporting. Available at: https://ecqi.healthit.gov/sites/default/files/2020-eCQM-Telehealth-Guidance-Document.pdf. Accessed August 19, 2020.
- eCQI Resource Center. Eligible Professional/Eligible Clinician eCQMs. Available at: https://ecqi.healthit.gov/ep-ec?year=2020. Accessed August 19, 2020.
- U.S. Centers for Medicare and Medicaid Services. QPP resource library. Available at: https://qpp.cms.gov/about/resource-library. Accessed August 19, 2020.
- American College of Surgeons. ACS COVID-19 telehealth resources. Available at: www.facs.org/covid-19/legislative-regulatory/telehealth. Accessed August 13, 2020.
- Smith WR, Atala AJ, Terlecki RP, Kelly EE, Matthews CA, Smith WR. Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic. J Am Coll Surg. April 30, 2020. Available at: www.journalacs.org/article/S1072-7515(20)30375-6/fulltext. Accessed August 13, 2020.
- Moazzami B, Razavi-Khorasani N, Dooghaie Moghadam A, et al. COVID-19 and telemedicine: Immediate action required for maintaining healthcare providers well-being. J Clin Virol. 2020;126:104345.
- Welch WC. Telemedicine benefits neurosurgery patients and providers. Bulletin Brief. August 11, 2020. Available at: www.facs.org/publications/bulletin-brief/081120/pulse. Accessed August 19, 2020.