What Is Known
- Telehealth on a relatively small scale increases access to care and satisfaction for some patients.
- Prior telehealth practices have been limited by insurance and regulatory barriers.
- General telehealth guidance provided from the American Academy of Pediatrics offers a basic framework.
What Is New
- Unprecedented, large-scale implementation of telehealth in response to the COVID-19 public health emergency.
- Sweeping regulatory changes alter license recognition, enforcement of the Health Insurance Portability and Accountability Act Privacy Rule, and reimbursement.
- Best practice recommendations for introducing and expanding telehealth in pediatric gastroenterology.
The COVID-19 pandemic has triggered an unprecedented expansion in telemedicine across the United States and around the world (1). In an effort to slow the spread of disease, particularly in high-risk health care settings, the United States Secretary of Health and Human Services announced a directive (2) for broad utilization of telemedicine (3). This article is intended as a guide to the rapid implementation of telehealth services for pediatric gastroenterologists.
The Institute of Medicine defines telemedicine as the use of electronic and telecommunications technologies to provide and support healthcare when distance separates the participants (4). Telemedicine capacity in the United States before the COVID-19 pandemic was limited by inadequate equipment, high costs of training, restricted insurance contracting, low reimbursement, and software constraints (5). The telehealth mandate has lowered some of these barriers (eg, reimbursement) and necessitated adaptation for others (eg, inadequate equipment) to facilitate the rapid expansion of telemedicine.
Some centers and providers have practiced telemedicine for several years within the confines of narrow regulations and limited financial incentives (6,7). In the midst of the current COVID-19 public health emergency (COVID-19 PHE), several key developments have facilitated widespread adoption: some states have loosened regulations, allowing physicians to provide medical care for patients across state lines regardless of licensure (8), reimbursement for telehealth visits has been increased (9), and enforcement of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule for confidential communication has been relaxed to accommodate communication platforms that may not comply with HIPAA standards (10).
Medical providers are adapting quickly to the call for widespread use of telemedicine. General guidance for conducting telehealth visits is available from the American Academy of Pediatrics (11), the American Medical Association (12), and adult gastroenterology societies (13). Our aim is to provide pediatric gastroenterology providers a relevant guide to implementation or expansion of telehealth practices during the COVID-19 PHE. The guide consists of 5 sections: guiding principles, planning and implementing visits, documentation and billing, adapting general telehealth principles to varied clinical settings, and specific applications of telehealth for children with inflammatory bowel disease (IBD) and intestinal failure (IF). In addition, sample templates for documenting telehealth encounters are included as supplemental digital materials (Supplemental Digital Content, http://links.lww.com/MPG/B819).
During the COVID-19 PHE, Medicare/Medicaid recognizes 3 major categories of outpatient telehealth encounters:
- Telehealth visits: A visit between a provider and new or established patient using audio and visual telecommunications.
- Virtual check-ins: Brief communication between the provider and an established patient via telephone, audiovisual application, secure text messaging, e-mail, or a patient portal.
- E-visits: Communication initiated by an established patient with the provider through an online patient portal.
The overarching aim of telemedicine interactions during the COVID-19 PHE is to provide patients and families with supportive care while minimizing exposure to disease in traditional healthcare venues (14).
PLANNING AND IMPLEMENTING VISITS
Planning and implementing telehealth visits can be divided into 3 parts: previsit, intravisit, and postvisit.
Teams must prepare to pivot in the face of worsening disease outbreak. As physicians and advanced practitioners face the possibilities of being called to the front lines or becoming patients themselves, team members must have a plan to care for each other's patients. Medical assistants and nurses may be redeployed to perform scheduling, technical support, and visit triage. Tasks to be accomplished in the previsit phase include the following:
Triage Visit Type
Standardize the process for redirecting in-person visits by creating clear guidelines for support staff to determine whether a patient's visit can be switched to a telehealth encounter. Without clear guidelines, a physician or nurse will need to individually review charts and triage patients, which adds significant time to the physician's role in the previsit phase. Standards of care for this process do not yet exist. Therefore, it may be reasonable in pediatric gastroenterology practice to conduct telehealth visits for all patients other than those with urgent, acute issues (eg, gastrointestinal [GI] bleeding, intractable vomiting, severe malnutrition, liver disease, fever with a central line). Common chief complaints that are amenable to telehealth include constipation, gastroesophageal reflux disease, feeding disorders, and weight management. As an alternative to previsit triage, some centers convert all visits to telehealth visits with the option to refer patients for an urgent evaluation with an on-site provider as needed. This possibility should be discussed with patients when scheduling and performing telehealth visits.
Train schedulers and repurposed medical assistants, nurses, or medical student volunteers to guide patients and families through previsit preparation, including downloading telecommunications software; registering for the electronic patient portal; and confirming all available phone numbers, e-mail addresses, and the preferred pharmacy. Provide prewritten scripts to the administrative team members conducting previsit preparation phone calls. A follow-up e-mail with a standardized, easy-to-read tip sheet may be sent to the patient or family to reiterate instructions discussed via phone. A follow-up call from the registration team 12 to 24 hours before the visit offers the opportunity to verify insurance and internet capabilities. A suggested workflow for support teams coordinating visits is provided in Figure 1A.
Patients who require additional planning and accommodations include those who need language translation services (spoken or sign language). In addition, patients without access to internet, computer, or smartphone are disadvantaged in their ability to participate in telehealth, accentuating healthcare disparities (15). Patients without audiovisual capabilities should be offered telephone visits as an alternative.
All clinical team members who will interface with patients via telemedicine software require training. HIPAA-compliant audiovisual platforms include Epic Haiku/Canto, Avizia, Cisco Jabber, PolyCom, Vidyoconnect, Microsoft Teams, and Zoom Healthcare. In the time of relaxed HIPAA compliance standards, patient-facing conventional modalities may also be used (eg, FaceTime, Facebook Messenger video chat, Google Hangout, Skype). However, care must be taken to inform the patients that these modalities may introduce additional privacy risks. Training methods for these applications may include synchronous video seminars, asynchronous recordings made by telemedicine-knowledgeable staff, and tip sheets with screen shots of implementation steps.
Practice groups would benefit from appointing a member as the telemedicine champion for outreach and support. In addition, each location must ensure that all necessary equipment is available and in working order, including computers, internet access, microphones and/or headsets, front-facing lighting, functioning iOS or Android devices, and a second phone line if possible.
Setting the Stage
Telehealth visits can take place anywhere. The provider should make efforts to create a professional environment. This includes conducting visits in a private location with a door that closes, low ambient noise, and the camera at eye level against a neutral background. To enhance patient privacy, consider playing white noise outside of the room and hanging a sign indicating that you are in session. Professional attire and a photo ID within the camera field are essential.
Inviting Multidisciplinary Partners in Health to the Visit
Telehealth visits provide the opportunity for collaboration with multidisciplinary teams located at various sites. These may include the primary GI provider, GI fellow, GI resident, dietician, nurse practitioner, nurse educator, social worker, patient, parents, home health aides, and nurses. Some platforms can accommodate multiple providers in the same visit. It is required to plan ahead to coordinate the roles of each participant and identify a team leader to facilitate the visit.
Rooming the Patient
Approximately 15 to 30 minutes before the telehealth visit, the registration team calls the patient to troubleshoot technical problems, ensure that all necessary software is downloaded, verify that both the child and parent/guardian will be present for the visit, confirm important information (eg, demographics, insurance coverage, pharmacy, current medications, medical history). It is also an opportunity to remind the patient to gather medicine containers to display later. The team should then invite the patient to enter the virtual waiting room. This simulates in-person workflows and allows the provider to focus on practicing medicine instead of waiting for the patient or providing technical support. A suggested workflow for the visit is outlined in Figure 1B.
Structuring the Visit
Begin each visit with introductions of all who are present, including those who may not be visible on camera. Clarify each person's name and relationship to the patient. Provide verbal consent using a prewritten script (Supplemental Digital Content 1, http://links.lww.com/MPG/B819) to explain the risks and benefits of video visits including limited examinations and diagnostic testing capabilities. Obtain a backup phone number for the patient or family and confirm location in case of the need to call for emergency services. In some states, it is necessary to confirm that the patient is present in a state where the physician is licensed; however, laws are changing rapidly during the COVID-19 PHE.
History and Physical
When performing medication reconciliation, take advantage of video technology to view each medication that the patient has in their possession and assess accuracy of the prescription and correct usage. Providers can visually examine patients and document overall appearance, mental status, activity level, body habitus, presence of scleral icterus, oropharynx, neck asymmetry or masses, cyanosis, respiratory effort, abdominal girth or distention, muscle wasting, extremity swelling or clubbing, skin rash or pallor, visible neurologic deficits, emotional affect, and presence of medical devices including alternative feeding devices and central venous catheters (Fig. 2). Photos of specific areas of interest can be uploaded to some electronic medical record systems. Some providers find it helpful to watch as a parent or caregiver palpates a child's abdomen. Visual rectal examinations may be performed but with careful discussion of the sensitivity of visualizing this area over a video, especially if using an application that is not HIPAA compliant. Unless critical to decision making, providers may opt to defer this part of the examination until a live encounter can take place.
The risks and benefits of potential procedures including imaging and endoscopy should be discussed in the context of COVID-19. Any elective studies and procedures should be deferred to minimize the patient's risk of exposure to the virus and to conserve use of personal protective equipment. Provide patients with a timeline for anticipated scheduling if at all possible and ask them to contact you within a specific timeframe to follow up regarding scheduling for deferred testing and procedures.
Addressing Technology Challenges
Despite optimal preparation, technological difficulties will arise for providers and patients. Instruct staff to contact the patient and family before the visit to ensure that they are prepared for the visit and instruct the patient to login to the visit 15 minutes before the appointment time. Empower patients to contact technical support (hospital technical support or readily accessible office staff trained in telehealth software usage) right away if issues arise. If there is no formal registration team available, consider assigning medical assistants or other ancillary staff to contact the patient and family 15 to 30 minutes before the visit to ensure that they are prepared for the visit. If the preselected telemedicine software fails, present the patient with a back-up software option (eg, Zoom, WhatsApp, FaceTime) but advise patients that these tools are not HIPAA compliant. Verbal telephone communication may serve as an option of last resort and the difference should be reflected in billing.
At the end of the visit, medical support staff can call patients to schedule follow-up visits, coordinate diagnostic testing, forward after-visit summaries, and clarify questions or discrepancies. This interaction provides an opportunity for the practice to survey patients for their feedback on the telehealth visit to improve the quality of care provided through this approach.
DOCUMENTATION AND BILLING
Documentation and billing of telehealth visits can be conducted like standard in-person office visits with additional notation of how the care provided differs from that in an in-person visit. The limitations of telehealth visits and, in particular, the narrow scope of visual examinations should be acknowledged. Visual observations can be documented as part of the examination (Fig. 2). Consent for virtual visits must be documented and can be obtained during the previsit phase by a registration team. Some patient portals include written consent forms to be signed before the video visit launches. Others obtain verbal consent at the start of the visit (script provided in Supplemental Digital Content 1, http://links.lww.com/MPG/B819) and include a written statement in the visit note indicating that verbal consent was obtained (Supplemental Digital Content 2, http://links.lww.com/MPG/B819). The decision to proceed with a telehealth encounter is ultimately a joint decision between the provider, patient, and family.
Billing expectations should be included with consent, indicating that the visit is a billable service with reimbursement determined by individual insurance carriers. Reimbursement for telehealth visits is equivalent to in-person encounters of the same complexity. Specific Current Procedural Terminology (CPT) codes and modifiers for telehealth are outlined in Table 1. The 3 major categories of outpatient telehealth encounters recognized by Medicare/Medicaid are billable with unique CPT codes (Table 1). Standard billing codes for in-person visits can be used to bill for telehealth encounters and will be reimbursed at the same level when specific modifiers are added to signify the use of telehealth technologies (Table 1). Billing for time is an accepted practice and may be beneficial especially when a visit does not otherwise fulfill all E/M guidelines. A provider can bill only for face-to-face time and cannot include time setting up the technology as part of the visit length. The visit note should include a specific statement of the visit duration and the percentage of time that was spent on counseling and education (see Supplemental Digital Content 3, http://links.lww.com/MPG/B819). It is absolutely necessary for the child to be present for the visit. If this is not possible or if the audiovisual connection fails, then the encounter can be carried on as a telephone visit, which is billable at a lower rate.
APPLYING GENERAL TELEHEALTH PRINCIPLES TO SPECIFIC CLINICAL SETTINGS INCLUDING IN-HOSPITAL CONSULTATIONS
In addition to addressing the need for social distancing to limit the spread of COVID-19 in the outpatient setting, telemedicine limits disease exposure and transmission and reduces personal protective equipment use in hospital settings. The principles described for general telehealth visits may be applied for pediatric gastroenterology consultations in the emergency department and inpatient settings. Collaboration with primary service teams is crucial to establish a successful care model for virtual consultations. Consulting teams should determine the necessity of in-person consultation based on their initial telehealth assessment. For common GI chief complaints (eg, constipation, abdominal pain), a virtual consultation may replace in-person consultation or serve to determine the necessity of in-person physical examination. Teams requesting consultation may benefit from receiving a list of common GI presentations amenable to virtual consultation.
Some telehealth platforms (eg, Avizia) are designed specifically for hospital-based encounters; however, alternate platforms (eg, FaceTime, Skype, Zoom) may be used during the COVID-19 PHE. Virtual in-hospital consultation may occur through 2 main modes of delivery: directly to patient (ie, to patient's personal smartphone) or through a hospital-furnished telemedicine cart equipped with the preferred application. The communication method used must be documented as described above, acknowledging risk of privacy loss when applicable.
TELEHEALTH FOR SPECIFIC PEDIATRIC POPULATIONS WITH CHRONIC DIGESTIVE DISEASES
Chronic pediatric digestive diseases that may be managed using telemedicine include chronic abdominal pain, celiac disease, chronic constipation, cyclic vomiting syndrome, dysphagia, eosinophilic esophagitis and gastroenteritis, food protein–induced enterocolitis, gastrostomy tube care, IBD, IF, and irritable bowel syndrome. For the purposes of this guide, we have chosen to highlight telehealth experiences in IBD and intestinal rehabilitation.
Inflammatory Bowel Disease
IBD, a chronic disease process requiring multidisciplinary care (16) and frequent monitoring (17), was ripe for application of telehealth before the COVID-19 PHE. IBD symptoms are debilitating (18) and increase healthcare utilization (19). Increased monitoring and access to care can positively influence IBD outcomes (20). Given that many children with subspecialty needs have limited access to appropriate care (21), telemedicine has the potential to revolutionize pediatric IBD management (22).
Use of telemedicine in IBD before the COVID-19 PHE has shown multiple benefits, including increased patient satisfaction, improved quality of life, and decreased clinic utilization (23–25). Compared to standard of care, use of telemedicine in IBD has not been associated with differences in rates of hospital admission, clinical relapse, or symptom severity (24,25). In addition, telemonitoring systems in IBD (eg, TELE-IBD) that use remote tracking of clinical data have shown promise in improving clinical outcomes, specifically in reducing hospitalizations (26). Given the overall benefits shown for patients with IBD enrolled in telemedicine and telemonitoring studies, the COVID-19 PHE provides additional impetus to implement these tools more broadly.
The most successful outcomes from intestinal rehabilitation occur when patients with IF receive center-based care from a multidisciplinary team (27). Given the limited number of specialized intestinal rehabilitation programs, they are often distant from the patient's home. Transitioning multiprovider visits to telehealth poses technical challenges but, once overcome, provides opportunities to conduct virtual home visits, educate multiple family and care team members simultaneously, and reduce risk of exposure for children who are medically complex. A pilot study performed from 2014 to 2016 by Raphael et al (7), showed that brief telehealth visits that focused on education after initiation of home parenteral nutrition (PN) reduced rates of central line–associated bloodstream infections. If implemented on a broader scale, this could have lasting impact to reduce morbidity and mortality associated with PN.
Before conducting a telehealth visit, patients and families should be prepared and consented. These visits provide the opportunity to assess the home environment and offer education about line care, PN administration, alternative feeding devices, and medication administration. Areas to focus on can include observing where PN is stored, visually reviewing medications, assessing whether patients have appropriate durable medical equipment and supplies, and supervising dressing changes or feeding. Virtual examinations can provide important information about the central line site, alternative feeding devices, and diaper rash. In addition, they can inform the provider by allowing observation of an abdominal examination performed by a parent, guardian, or home health aide. These visits can provide an opportunity to meet home nurses, connect with multiple family members, and identify risks for readmission and complications.
Telehealth visits can be combined with home care visits. The home care nurse can perform an observed or even a directed physical examination. Combining periodic telehealth visits with local assessment of patient weights and laboratory results can facilitate assessment of nutritional status and disease management.
Successful implementation of large-scale telemedicine depends upon mutual support for all team members and flexibility in roles and responsibilities. As the workflow evolves, methods established in some subspecialty clinics (eg, intestinal rehabilitation and IBD) can be adapted to others including hepatology, nutrition, aerodigestive, and celiac disease. As the response to the current PHE evolves and, eventually, resolves, provisions made for billing, liability, and HIPAA protection for telehealth may change. The work that is, however, done now to establish best practices for telehealth in pediatric gastroenterology will form the foundation for future innovations in telehealth for children with digestive diseases beyond the COVID-19 pandemic. For telehealth, the future is now.
1. Reeves JJ, 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
2020; doi: 10.1093/jamia/ocaa037.
2. Secretary Azar announces historic expansion of telehealth access to combat COVID-19. Health and Human Services Website. https://www.hhs.gov/about/news/2020/03/17/secretary-azar-announces-historic-expansion-of-telehealth-access-to-combat-covid-19.html
. Published March 17, 2020. Accessed March 31, 2020.
3. Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med
2020; doi: 10.1056/NEJMp2003539.
4. Field MJ, ed. 1996. Telemedicine: A Guide to Assessing Telecommunications for Health Care. Washington, DC: The National Academies Press. http://www.nap.edu/catalog/5296.html
. Accessed March 30, 2020.
5. Kruse SC, Karem P, Shifflett K, et al. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare
6. Venkatesh RD, Campbell EJ, Thiim M, et al. e-Consults in gastroenterology: an opportunity for innovative care. J Telemed Telecare
7. Raphael BP, Schumann C, Garrity-Gentille S, et al. Virtual telemedicine visits in pediatric home parenteral nutrition patients: a quality improvement initiative. Telemed J E Health
8. Goguen D. States allow doctors to practice across state lines during COVID-19 crisis. Medscape. Published March 25, 2020. Accessed April 1, 2020. https://www.medscape.com/viewarticle/927495
9. Medicare Telemedicine Health Care Provider Fact Sheet. Centers for Medicare and Medicaid Services Web site. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
. Published March 17, 2020. Accessed April 1, 2020.
10. Office for Civil Rights. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. Health and Human Services Web site. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
. Published March 30, 2020. Accessed April 1, 2020.
11. Brent A, Chuo J, Freeman B, et al. Telehealth support compendium. American Academy of Pediatrics website. https://www.aap.org/en-us/professional-resources/practice-transformation/telehealth/Pages/Getting-Started-in-Telehealth.aspx
. Published 2020. Accessed March 30, 2020.
12. AMA quick guide to telemedicine in practice. American Medical Association Web site. https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice
. Updated April 2, 2020. Accessed April 2, 2020.
13. ACG News Team. Top five things gastroenterologists should know about telemedicine. American College of Gastroenterology Web site. https://gi.org/2020/03/20/top-five-things-gastroenterologists-should-know-about-telehealth/
. Published March 20, 2020. Accessed April 3, 2020.
14. Portnoy J, Waller M, Elliott T. Telemedicine in the era of COVID-19. J Allergy Clin Immunol Pract
2020; doi: 10.1016/j.jaip.2020.03.008.
15. Stavroulaki T. Mind the gap: antitrust, health disparities and telemedicine. Am J Law Med
16. George L, Cross R. Telemedicine platform myIBDcoach reduces hospitalisations and outpatient gastroenterology visits in patients with IBD. BMJ Evid Based Med
17. Patil SA, Cross RK. Current landscape of telemedicine practice in inflammatory bowel disease. Inflamm Bowel Dis
18. Bernklev T, Jahnsen J, Lygren I, et al. Health-related quality of life in patients with inflammatory bowel disease measured with the short form-36: psychometric assessments and a comparison with general population norms. Inflamm Bowel Dis
19. Kappelman MD, Porter CQ, Galanko JA, et al. Utilization of healthcare resources by U.S. children and adults with inflammatory bowel disease. Inflamm Bowel Dis
20. Strohl M, Gonczi L, Kurt, et al. Quality of care in inflammatory bowel diseases: what is the best way to better outcomes? World J Gastroenterol
21. Bethell CD, Kogan MD, Strickland BB, et al. A national and state profile of leading health problems and health care quality for US children: key insurance disparities and across-state variations. Acad Pediatr
2011; 11: (3 suppl): S22–S33.
22. Ray KN, Demirci JR, Bogen DL, et al. Optimizing telehealth strategies for subspecialty care: recommendations from rural pediatricians. Telemed J E Health
23. Huang VW, Reich KM, Fedorak RN. Distance management of inflammatory bowel disease: systematic review and meta-analysis. World J Gastroenterol
24. Aguas Peris M, Del Hoyo J, Bebia P, et al. Telemedicine in inflammatory bowel disease: opportunities and approaches. Inflamm Bowel Dis
25. Li SX, Thompson KD, Peterson T, et al. Delivering high value inflammatory bowel disease care through telemedicine visits. Inflamm Bowel Dis
26. Cross RK, Langenberg P, Regueiro M, et al. A randomized controlled trial of TELEmedicine for patients with inflammatory bowel disease (TELE-IBD). Am J Gastroenterol
27. Merritt RJ, Cohran V, Raphael BP, et al. Intestinal rehabilitation programs in the management of pediatric intestinal failure and short bowel syndrome. J Pediatr Gastroenterol Nutr