At the tail end of 2019, a new disease, coronavirus disease 2019 (COVID-19), emerged and escalated into a worldwide pandemic that forced the healthcare industry to restructure itself to accommodate the rapid influx of critically ill patients, preserve medical equipment, and protect the lives of healthcare workers. As part of the response, traditional outpatient medical care came to a standstill, and new systems to provide care for non–COVID-19 patients became necessary. One of the most effective approaches has been the use of telehealth. Telehealth encompasses telemedicine with clinical care for patients, teleresearch, teleconsultation, and tele-education. Although telehealth includes telemedicine, the two terms are commonly used interchangeably.1
Telemedicine is a powerful tool for patient care that allows for the diagnosis, treatment, and prevention of disease without in-person contact. It can support the continuation of provider training, administrative meetings, medical education, patient education, public health, and clinical activities. Rehabilitation therapists and psychologists have been using telerehabilitation to improve access and support independent living.2 Although there are severe shortages of pediatric rehabilitation physicians, especially in rural areas, telemedicine utilization has been limited.3
The aim of this article is to describe the changes brought about by the COVID-19 pandemic in legislation, insurance coverage, and practice that have enabled the increased use of telemedicine in a pediatric rehabilitation outpatient setting. Potential healthcare approaches to clinical encounters, logistics and processes, as well as the benefits and barriers to its implementation as a standard of care are described. This article also will provide suggestions for future research and legislation.
PRE–COVID-19 BARRIERS TO TELEMEDICINE
As of 2018, only 47.6% of hospitals and 25% of the intensive care units in the United States had the capacity to provide telemedical services.4 Before the COVID-19 crisis, the barriers to telehealth included the following: lack of Internet, broadband access, appropriate equipment and training, as well as issues with reimbursement, malpractice, licensing, and Health Insurance Portability and Accountability Act (HIPAA). Broadband access, which the Federal Communications Commission defines as the minimum requirement for telecommuting or synchronous video sharing, is not available for 10% of Americans and approximately 35% of those living in tribal areas.5 Furthermore, mobile health, remote patient monitoring (with the exception of Alaska and Hawaii), and store-and-forward (asynchronous) transmission of patient data were not reimbursed by Medicare. Telehealth visit location was defined by the patient’s location, thus requiring physicians to acquire full or partial licensure and comply with the regulations of that state. In addition, a variety of medical services, including prescription of controlled substances, was also restricted. Although the number of malpractice suits related to telehealth is low, not all carriers provided malpractice insurance for telehealth encounters. To address this, the Federation of State Medical Boards is in the process of creating a model contract for practicing medicine across state lines, which 22 states have now adopted.
Before 2020, Medicaid had been in the forefront of viewing telemedicine as a cost-effective alternative to traditional in-person care and has provided states with the flexibility to determine which services and providers to reimburse for telemedicine care. By 2019, 37 states and the District of Columbia had parity laws that mandated private payer reimbursement for telemedicine services at the same rate as in-person care.6
IMPACT OF COVID-19 ON TELEMEDICINE
Since the beginning of the pandemic, social distancing recommendations and stay-at-home orders in many states severely affected the total number of people who could be seen in person. To address this backlog of patients, the Centers for Medicare & Medicaid Services (CMS) released Public Health Emergency (PHE) regulatory changes on April 6, 2020, as a part of the interim final rule. On April 9, 2020, the CMS released the COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing (“COVID-19 Frequently Asked Questions”) to address reimbursement disparity and regulatory inconsistencies around telemedicine services, which also related to the overall PHE and the CMS Waiver of the 1135 Rules for the duration of the PHE.
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES RESPONSE DURING THE COVID-19 CRISIS
The following amendments were made to CMS Interim Rule7–10:
- Amendments for physician practice
- ο Waives the requirement for physicians to hold a license in the state in which they provide services.
- ο Waives requirement for telemedicine limited only to previously established patients.
- ο Eliminates telemedicine visit frequency limitations.
- ο Telemedicine now fulfills face-to-face visit requirements in inpatient rehabilitation facilities, hospice, durable medical equipment prescription and home health settings. Remote patient monitoring can be done for COVID-19 or other chronic conditions.
- • Connectivity
- ο Providers are allowed to evaluate Medicare beneficiaries who have access to audio phones without video capabilities.
- ο HIPAA waiver allows applications to include commonly available interactive apps with audio and video capabilities such as Apple FaceTime, Google Hangouts, Zoom, Skype, Doximity dialer, Amazon Chime, and GoToMeeting. Providers are encouraged to notify patients about privacy risks and enable all encryption and privacy mediums.
- ο Facebook Live, TikTok, Twitch, and similar public facing video communications are not approved for telemedicine.
- ο Health and Human Services and Office for Civil Rights will exercise its enforcement discretion and will not impose penalties for noncompliance with the HIPAA rules in connection with the good faith provision of telehealth using any nonpublic facing audio or video communication products.
- ο Through the Coronavirus Preparedness and Response Supplemental Appropriations Act, Medicare can pay for televisits regardless of the geography.
- ο Cost sharing is waived and reimbursed at the same rate as regular in-person visit.
- ο Medicaid and private insurance reimbursement policies vary from state to state.
- Increased accessibility for medical services
- ο In the Interim Final Rule, the CMS identified more than 80 additional services that may be provided via telemedicine. Speech, physical, and occupational therapy and acute inpatient rehabilitation are among those that are temporarily allowed.
- ο Permit Medicare enrollees to use out-of-network providers in an emergency.
- ο As of August 3, 2020, an Executive Order on Improving Rural Health and Telehealth Access was signed to ensure the virtual care continues after the pandemic in rural areas.
TELEMEDICINE IMPLEMENTATION IN PEDIATRIC REHABILITATION
Trained clinicians at specialized schools for children with conditions such as cerebral palsy (CP), autism, visual, or hearing disabilities have long used telemedicine to provide quick and efficient care for their students. Studies looking into satisfaction with telemedicine by pediatric physiatrists and caregivers of children with developmental disabilities and/or who require complex medical care in rural areas have shown good results.11,12
A study using telemedical concussion evaluations by remote neurologist for real-time athletic sideline assessment of concussion found a high level of agreement between remote and face-to-face providers with regard to examination findings and remove-from-play determinations.13 More recently, a Canadian spasticity management task force determined telemedicine to be an effective tool for remote management of patients with spasticity.14 Currently, the University of California, Davis, is conducting the School-Based Tele-Physiatry Assistance for Rehabilitative and Therapeutic Services clinical trial, which aims to evaluate the outcomes of implementing pediatric physiatry telehealth services in school-based setting.15
Tele-education provides medical education using audiovisual and real-time interaction between the presenter and the learner, especially to rural healthcare workers.1,16 Coronavirus disease 2019 brought tele-education to the mainstream, from providing journal clubs to pediatric rehabilitation fellows to continuing medical education by national organizations such as the American Academy of Physical Medicine and Rehabilitation and the Association of Academic Physiatrists.17,18 Since the pandemic began, tele-education has become the main source of learning and, most likely, will continue to be an important aspect in medical education in the post–COVID-19 era.
Teleconsultation has been used to provide care to rural areas with shortages of pediatric rehabilitation specialists. In a study by Marcin et al.,19 parents/guardians and physician satisfaction with telemedicine encounters for children with special healthcare needs that live in rural, medically underserved communities were either excellent or very good with both groups. Similarly, in a study from Manitoba of 20 adolescents with concussions, telemedicine management of their postconcussive care resulted in resolution of symptoms in 90% with a cost avoidance of US $40,972.94.20
The COVID-19 pandemic caused sudden and significant disruptions in the service delivery at our institution located in the Bronx—one of the hardest hit urban areas of New York City. Our population is extremely diverse and socioeconomically disadvantaged. To protect pediatric patients, families, and health professionals, it was crucial to make swift changes to the outpatient rehabilitation services provided for children with special needs.
Within days of the statewide closure of routine outpatient clinics, our department began transitioning to telehealth with the help of institutional leadership, which provided the framework for the process. Many new procedures and processes had to be created and implemented, from scheduling by support staff to educating parents on the telehealth process. It became necessary for physicians to develop new proficiencies in obtaining informed consent for virtual visits, ensuring patient privacy, manipulating audio/video devices, and navigating the telehealth platform.
Within the first 3 mos of the COVID-19 pandemic, 367 televisit encounters were scheduled for the pediatric physiatry clinics. Two hundred twenty-two of these encounters were by telephone, whereas the remaining 145 were televideo visits. Of these, 108 telephone visits (48.6%) and 105 televideo visits (72.4%) were completed successfully. Early experience suggests that telemedicine could be used successfully in pediatric rehabilitation. It was found that telemedicine provided the ability to engage directly with patients and other providers and eliminated the need for specialized transportation and difficult commutes.
Most parents were satisfied with the visits and expressed their gratitude to the physicians for the continued care that their children received during the lockdown. It was also clear that parents understood the limitations of telehealth in musculoskeletal and neurological evaluations, especially in the assessment of muscle tone and joint ranges.
Our institution leveraged its experience to transition to other areas of telemedicine including webinars for patients, family education, establishing therapy services for postsurgical orthopedic conditions, remote adaptive technology, and orthotics management. The authors were also able to use teleconsultations for assessment of neonatal intensive care unit patients, neonates with brachial plexopathy and clavicular fractures and to provide nonemergent evaluations for pediatric patients in long-term care facilities.
Our department was able to efficiently use a variety of tele-education platforms for graduate medical education and faculty development forums and provide interactive learning for practitioners at different locations via video conferencing. Before and during the pandemic, the authors’ institution participated in virtual learning of early detection of CP and general movement assessment based on case presentations. We also educated young adult patients with intellectual and developmental disabilities on independent living and academic and work opportunities in the community through video. Tele-education became the main tool for teaching fellows and residents.
We are continuing to improve our telemedicine platforms for the provision of pediatric rehabilitation medicine services for our patients within the guidelines of the department of Health and Human Services and the Office for Civil Rights.
TECHNIQUES AND CHALLENGES OF THE TELEMEDICINE PEDIATRIC MUSCULOSKELETAL AND NEUROLOGICAL EVALUATION
One of the advantages of telemedicine is the ability to observe and assess a child’s functional status in their own home environment and evaluate durable medical equipment needs and barriers to access in their home. Although it is not possible to palpate or perform a hands-on examination, it is possible to perform a fairly accurate and comprehensive pediatric neurologic and musculoskeletal examination through the telemedicine platform by using the parent and/or caregiver as a physician extender to perform the physical examination. It is essential that practitioners appropriately gauge the ability and comfort of the caregiver before beginning an examination.
Based on our experience, provided hereinafter is the information on equipment that was found most useful (Table 1). History taking remains fairly unchanged. Also included are essential pointers for taking a developmental history (Table 2) and neurological and musculoskeletal examination (Table 3).
|Equipment Recommended During a Pediatric Rehabilitation Televisit Encounter
|Patient and Physician
|• Computer, Smartphone, or tablet with camera, microphone, and speaker
• Reliable Internet connection
|• Institutional established software platform compliant with HIPAA requirements
• Tools that can help in the physical exam such as virtual protractor or a small goniometer.21,22
• The physician can use a doll to illustrate the appropriate way to perform a movement in the exam.
|• Medical equipment and orthoses available during the visit
• Toys and firm surfaces (bed or mat on the floor) to make the examination more feasible.
TABLE 2 -
Tips for performing the pediatric developmental evaluation
||Interview via Video
||• Gestational age
• Labor and delivery
• Neonatal period
• Immunization history
||• Familial medical issues
• Sibling health
||• Gross motor
• Fine motor
• Language barriers
• Personal-social behavior
• Input from teachers/therapists
|Development and growth
||• Growth and development compared with children of similar age
• Measurements: height and weight
• Head and skull: tape measure
TABLE 3 -
Tips for performing the pediatric neurological and musculoskeletal evaluation in a telemedicine visit
||Inspection Via Video
||Assess mood, behavior, and affect
||Fluency, comprehension, naming, repetition, reading, and writing (drawings, artwork, scrapbook, journal)
||• General appearance
• Limb length discrepancies
• Joint deformities
• Neck: asymmetrical rotation, torticollis
• Skin: rashes, bruising, bleeding, pigment changes
• Spine: scoliosis, kyphosis, lordosis
• Hands: abnormal crease, polydactyly, intrinsic atrophy
• Feet: metatarsus varus, club/flat foot, cavus foot, equinus, claw toes
• Leg: genu varum/valgum, tibia vara
||• Visual acuity
• EOM, nystagmus, pupil symmetry
• Shoulder: shoulder shrug
• Tongue: midline protrusion/deviation
||• Muscle bulk
• Range of motion (upper and lower limbs)
• Strength: antigravity strength, asymmetry
• Stand from seated chair/floor position, climb stairs
• Tone: difficult to assess
• Abnormal movements: assess for bradykinesia, chorea, tremor
||Assess for light touch
||Coordination: assess for dysmetria, Romberg test
||• Walk in tandem/toes/heels, hop on one foot
• Assess for GMFCS if CP (level I–V)
||Deep tendon, plantar, Babinski
|Brace and wheelchair
||• Assistive devices (wheelchair, walkers, etc.)
• Ask to see patient’s equipment and evaluate whether it is appropriate/requires alternative size/style
GMFCS, Gross Motor Function Classification System.
POTENTIAL SHORTCOMINGS OF TELEMEDICINE IN PEDIATRIC REHABILITATION
General inspection, examination of most cranial nerves, motor examination, range of motion, coordination, balance, and gait can be done during a televideo visit, but there remains a dependence on the caregiver’s ability to understand instructions, observe, and describe the findings during a telephone encounter as well as the child’s cooperation. Palpation and tone assessment remain challenging in both, televideo and telephone examinations.
Other challenges include difficulty instructing caregivers how to download the necessary platforms, having sufficient bandwidth for good quality video images1 and affording the data plans that may be prohibitive for low-income households. Furthermore, 2020 data show that only 77% of Americans have smartphones.23
In addition to the difficulties faced by the caregiver, research shows that physician resistance is one of the top barriers to implementing telehealth services.24 For many providers, telehealth is not easily integrated into their daily workflow, because it requires extra time and additional equipment.25,26
There are also financial implications to the physician and to the hospital as a result of COVID-19 and the implementation of telehealth. Because of the decrease in patient visit volume, nonemergent procedures, reimbursement rates, waiver of copay, and loss of “facility” fees, many small hospitals and private practices have experienced a precipitous drop in revenue during the pandemic. Although the CMS increased telemedicine reimbursement during the COVID-19 pandemic, many providers have yet to receive the promised payments, and it remains unclear that once the PHE is over, there may be a return to previous low-level or nonexistent payment for telemedicine services.
Finally, defined liability protections with regard to telehealth must be clarified by each state and/or hospital to protect providers. Credentialing, licensing, reimbursement, and malpractice guidelines are continuously evolving as the COVID-19 pandemic has forced an increasing number of physicians to adopt telehealth as a primary means of patient assessment. Understandably, providers may be wary of the medicolegal and liability pitfalls.
POST–COVID-19 ERA: THE FUTURE OF TELEMEDICINE
Financial Impact and Sustainability
Payment is an essential element to ensure telemedicine’s continued sustainment and integration into our healthcare system. With the onset of COVID-19, the federal government has relaxed all restrictive regulations for telemedicine, including those for reimbursement.1 However, to make telemedicine a sustainable modality, these measures should be continued in the future. Legislation to make permanent the August 3, 2020, Executive Order on Improving Rural Health and Telehealth Access would be an example of the support needed to make telemedicine sustainable. In addition, third-party payers and private investments from pharmaceutical and technology industries can enhance further telemedical development. By providing new devices and upgraded network systems, these industries can help improve patient care and help generate revenue.27
Telemedicine provides a potential benefit to improve the quality of care for pediatric patients. It increases patient access by offering convenient, flexible visits, which are more time and cost-efficient. It saves on transportation costs and reduces absences from school or work.28 A systematic review of patient satisfaction with telemedicine services found that all 32 examined studies demonstrated good levels of patient satisfaction, which our own anecdotal patient experience supports.29
Many pediatric subspecialty services, such as pediatric rehabilitation, are limited in remote and underserved areas. Through teleconsultation by pediatric physiatrists, patients with disabilities living in remote locations can receive standard rehabilitation care.30 Using telemedicine, pediatric physiatrists can experience virtual home visits to assess a child’s home environment and prescribe or recommend appropriately sized and configured durable medical equipment.
Advancements in wireless communication technology, such as 5G, will revolutionize healthcare and telemedicine by creating a system where all the devices and platforms are connected with improved reliability and cloud-based storage. It will provide data and quick responses with real-time and low-latency imaging.27 A faster Internet speed will enable many innovative applications such as motion sensors, exoskeletons, and robotics that can be used in telemedicine without image display or data transfer delay. Physicians will be able to receive and analyze the precise data obtained from a patient’s movements. Virtual and real-time remote rehabilitation coaching will also be possible.27 New technologies may permit access to a child’s baclofen pump and allow a dose adjustment to be performed remotely, saving the cost for transportation, especially medical transport services that many of these children rely on. This is predicated on the assumption that these services will be made more universally accessible, an ongoing issue in rural areas and particularly in indigenous communities, as noted previously.
Telemedicine can provide new tools such as streaming videos and interactive websites to educate patients and families on chronic disease management and provide continuing medical education for providers.28 New 3-dimensional video conferencing is more advanced than traditional teleconferencing as it allows a more robust telepresence, simulating an environment in which a speaker and audience are in the same room. It is an excellent tool for teleconsultation, multidisciplinary meetings, medical lectures, resident training, and procedure demonstrations.
Besides standard research protocols that can be modified for teleresearch, new avenues can include studying data algorithms helpful for better treatment,27 efficacy of tele-education, and validating tele-examination and telehealth tools.
Telemedicine is a fast-growing platform that offers both patients and practitioners a safe and effective medium for communication, evaluation, and treatment in the field of pediatric rehabilitation, especially during the current COVID-19 pandemic. A steady downtrend in government and third-party payer restrictions and regulations, accompanied by growing acceptance from parents and caregivers of pediatric rehabilitation patients, has allowed telemedicine to become one of the most practical and successful forms of evaluation and treatment during the pandemic. It has not only helped sustain patient healthcare but also made a tremendous impact on continued medical education.
As the world continues to battle the persistent growth of COVID-19, telemedicine will expand with new and innovative video platforms, higher-speed Internet, and 3-dimensional technology. The future of telemedicine will rely on technological developments, supportive governmental and third-party payer policies and funding, resolution of HIPAA issues, clarification on liabilities, and overcoming state-to-state regulations. With the continued support of new legislation, governmental agencies, payers, and hospital administration, telemedicine can optimize patient care and become one of the most effective tools of our coordinated healthcare system for years to come.
The authors thank Dr Matthew Bartels, Chairman, Department of Rehabilitation Medicine, Montefiore Medical Center, for his support for reviewing the manuscript.
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