EPtalk by Dr. Jayne 4/23/20

Telehealth is a hot topic in the virtual physician lounge, with various specialty organizations providing cheat sheets and other reference materials to help practices figure out how to get paid. The American Academy of Family Physicians put together a nice table and flow chart identifying the appropriate E&M codes to use for various clinical and technology scenarios.

As the coronavirus response shifts, some states are allowing their emergency licensing waivers, which allowed many of us to see telehealth patients across state lines without separate licenses in those states, to expire. The recent expansion of telehealth coverage by the US Department of Health and Human Services also allowed providers to avoid HIPAA penalties for the good-faith provision of telehealth during a public health emergency, which led to a boom in use of things like Skype, FaceTime, Facebook Messenger, and other non-secure platforms. It’s unclear exactly how long the “public health emergency” status will last and how much warning we’ll have before the original rules return in force.

Although many healthcare delivery organizations are strapped for cash due to declines in elective procedure revenue, it’s time for them to start thinking about how they’ll transition to a HIPAA-compliant solution. In addition to the HIPAA angle, providers deserve better than using consumer apps. To have the best efficiency and patient safety features, telehealth platforms should integrate with the EHR and scheduling system for streamlined documentation and follow up.

I’ve heard of a couple of health systems looking at telehealth as a way to reduce their physical footprint and get out of costly leases. One executive I talked to spoke of turning some of their offices into the medical equivalent of WeWork sites, where providers could purchase just the time and space they need for face-to-face visits, which may fall below 25% in some specialties.

Stories about providers having their hours cut are everywhere, along with recent reports that healthcare staffing giant Envision Healthcare might be preparing to file for bankruptcy. The company has over $7 billion of debt. The entry of private equity into healthcare in recent years has sucked money out of the system at an alarming rate. Perhaps its time for hospitals to go back to employing physicians and treating them like valued members of the community instead of commodities.

Several physicians have asked me if I had read the statements from the Office of the National Coordinator regarding flexibility with the Interoperability Rule, and I had to admit that I hadn’t. The bottom line is the ONC and CMS, along with the HHS Office of the Inspector General (OIG – just wanted to see how many abbreviations I could string together) announced “a policy of enforcement discretion to allow compliance flexibilities regarding the implementation of the interoperability final rules announced on March 9th.” They went on to say that this “flexibility” is specifically due to the COVID-19 public health emergency. The discretionary period will run for three months past the original compliance dates, but I wouldn’t be surprised if it ends up being extended.

I was initially excited to see an email from Provation offering a “free COVID-19 order set and care plan” in order to “keep all our healthcare heroes equipped with the latest evidence-based order set and care plan content available for COVID-19.” Unfortunately, it requires provision of your email address and company info prior to access, followed by acceptance of terms of agreement that say you can download a single PDF copy “solely for evaluation purposes.” Given the lack of proven treatment for COVID-proper, there wasn’t anything too earth shaking in it.

I was pleased to see the American Academy of Family Physicians come out with a forceful statement about the lack of evidence for off-label use of medications for COVID. Physicians are getting numerous requests for unproven drugs, and those who give in to the badgering are inadvertently causing shortages for people that need the drugs for their actual approved use.

A colleague clued me in to a Miami organization that mailed her mother a bottle of hydroxychloroquine without her requesting it, along with information stating that patients were being placed on it as a preventive. I was happy to see that references to that activity have been sanitized from its website, although the South Florida Sun Sentinel preserved the CEO’s statements and advocacy for the drug for posterity. I hope regulators and license officials take the time to investigate any shenanigans that have already occurred.

I was also happy to see the announcement of an AMIA webinar next week focusing on Electronic Case Reporting. This is a problem I’ve been trying to solve for a client. Due to geographic spread, they have to report COVID-positive cases to dozens of public health authorities, all of whom have different forms. Required transmission modalities include phone, fax, email, web forms, and snail mail. The client has largely given up on reporting, preferring to ask for forgiveness rather than permission. Hopefully the pros on the call will have some ideas to help so I can stop tearing my hair out. If any readers have inside scoop, please share with the rest of the class.

I was less happy to see the CMS document detailing strategies on how to reopen healthcare delivery in the US. First off, its title “Opening Up America Again” is a little too close to a political slogan than should be permissible with an official CMS document. I detest the use of the word “America” as a synonym for “the US” because it makes us appear ignorant of the fact that “the Americas” are a big place inhabited by lots of people other than us.

In short, the document recommends that organizations use telehealth when they can, but in-person care can resume in areas that have “the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary.” Consideration should be given to facilities, workforce, testing, and supplies.

However, the CMS statement on Personal Protective Equipment (PPE) is weak. Basically they are recommending only surgical facemasks for healthcare workers unless high-risk procedures are being performed, and “patient should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.” No mention was given to the relative ineffectiveness of cloth face coverings or the lack of science supporting their use, nor of the studies that show that in some circumstances cloth face masks can actually increase transmission of infection.

On the delivery side, the plan is to “conserve PPE,” which basically means healthcare organizations can require their employees to use items in ways that contradict documented approved uses and increase risk to staff. I fully understand that we can’t just use new masks for every patient like we used to, but I would love to see Seema Verma have a conversation with my friend Lil, a pediatric OR nurse who was denied a new mask by an OR supervisor despite her mask being soaked with sweat (and likely ineffective, since you’re not supposed to wear them if they’re saturated).

The document also calls for routine screening of workers and designation of “COVID-19 Care zones” and “Non-COVID Care” (NCC) zones, with separate buildings or separate entrances in the same building and with staff not crossing from zone to zone. It goes on to say that “all patients must be screened for potential symptoms of COVID-19 prior to entering the NCC facility, and staff must be routinely screened for potential symptoms as noted above. When adequate testing capability is established, patients should be screened by laboratory testing before care, and staff working in these facilities should be regularly screened by laboratory test as well.” I’d love for someone to sit down and explain how that should work in the average primary care office or urgent care, because it doesn’t feel like CMS is thinking beyond the hospital walls.

What do you think about the plan to reopen healthcare in the US? Leave a comment or email me.

Email Dr. Jayne.