COVID-19 has changed the world as we have come to know it in a matter of days. Truly everyone has been affected significantly by the pandemic, and those of us in the world of pain and neuroscience are no different. As we are all faced with both short and long-term challenges on how to navigate this complicated time, ASPN has formed a COVID-19 Task force to help provide guidance during these trying times. ASPN was founded on the principles of leveraging the innovation and leadership of the top minds in our field, and the COVID-19 taskforce is no exception to these founding principles. Our pledge is to continue to push out responsible guidance based on evidence, global and local health organization recommendations, and expert consensus. As we hopefully move past this crisis in the following months, ASPN will also be there to provide the most up to date clinical content so that when we get back to tending to our patients, we will be ready and well informed
As this coronavirus pandemic continues to rage on we forget that for viruses there is no race, gender, border, country that determines its verocity or speed of spread. Ultimately, it tests the resolve of humanity to come together, to make us introspect and work together in a way that only nature can do every 100 years in our ongoing collective history. It calls for us to unite, to set aside differences, to find common ways to fight this enemy from spreading.
When this taskforce was formed, it was done with the call for unity among our specialty. Pain is truly one of the greatest challenges that has faced the medical community given that just prior to this event we were facing another large public health issue mainly the opiate crisis. Now as we shift our efforts to combat a global public health emergency we have to be mindful that decisions we make as a specialty globally will set the framework for the future. This responsibility cannot be understated or undervalued. We must work hard to understand the evidence, understand the data, and understand the plight of our patients within the context of the larger public health crisis facing us.
This newsletter is the beginning of several resources we want to provide to the global pain community. While these guidelines, recommendations, stories, and experiences may not apply to each individual physician, practice, or patient, its our way to support each other. It is our way to help the global pain community navigate a very difficult time where we are forced to make important decisions on keeping our businesses open, while weighing out the safety of our loved ones, staff, and close friends. Its at these times where leadership is most important. Not individual leadership but collective leadership.
So with that we hope that this newsletter encourages teamwork, unity, discourse about the future of our field. Great things can truly be accomplished when we set our hearts and minds to solving problems together. In it together, we will get through it together.
Tune in to the ASPN/PSPS Joint Webinars for more information.
Summary Document Prepared by ASPN COVID-19 Taskforce – Dr. Jason Pope MD, Dr. Erika Peterson MD, Dr. Sean Li MD, Dr. Jonathan Goree, Dr. Dan Bates MD, Dr. Stan Golovac, MD, Dr. Jonathan Carlson, MD
The COVID-19 pandemic has led to extraordinary challenges in patient care. CDC and WHO recommendations for self-isolation and social distancing to “flatten the curve” on exposure to contagious individuals have altered how clinicians care for patients.
Based on recommendations by the Surgeon General and the American College of Surgeons elective surgeries have been postponed, leaving patients uncertain as to their future care plans.
Office visits are being rescheduled, postponed, or moved to a telemedicine strategies, where possible.
Telemedicine typically have three avenues for patient engagement, Virtual check-ins electronic visits (e-visits), or telehealth visit.,
Less than a week ago, the Centers for Medicare Services (CMS) relaxed the guidelines to allow for virtual visits with less compliant HIPPA video requirements and also loosening the patient’s location eligible for telehealth, now including the patient’s home. Some insurers and states have created new flexibility in refilling prescriptions through telehealth visits and for longer durations. Despite these changes, pain patients may still have to visit their physician’s office in order to get prescriptions refilled.
COVID-19
Patients with chronic pain are established with a chronic pain treatment physician under a controlled substance agreement. These patients have long-term relationships with a single medical practice that oversees their medications and physical symptoms.
Often these patients are older, have several additional medical conditions that make them more vulnerable to COVID-19, and require assistance with transportation to office visits, meaning that another individual must accompany them.
Many of these patients are on high-risk medications, including low-dose opioids, anti-depressants, and anti-seizure medications that can cause side effects or withdrawal symptoms with abrupt cessation.
Many of the symptoms of acute opioid withdrawal – shivering, body aches, hypertension, tachycardia, and fever – could be confused for COVID-19 symptoms, causing increased burden on our already stressed healthcare system.
COVID-19 & Telemedicine
An in-person visit to a clinic for these established patients with no new medical problems in order to renew long-standing prescriptions is a perfect use of telehealth. The remote visit allows for the interview and taking a history physical examination by video and patient counseling. Thanks to prescription drug monitoring programs, chronic pain physicians have the tools to remotely evaluate any controlled medications that a patient has obtained and discuss risks, benefits, and side effects effectively. Telehealth also decreases traffic in the office, which protects healthcare workers from exposure to community members who might be asymptomatic COVID-19 carriers and limits the exposure of vulnerable patients to these carriers as well.
ASPN supports the use of telehealth as a viable method of delivering patient care while limiting COVID-19 exposure to both clinicians and patients. During times of an unprecedented global healthcare crisis, we recognize that chronic pain patients are vulnerable to such disruption to care. They are at risk for pain exacerbations that require unnecessary emergency room visits leading to potential harmful viral exposure. Patients may run out of stable medications and suffer unpleasant withdrawal symptoms. Intrathecal pump patients can experience potentially lethal withdrawal symptoms from running out of medications in their pumps and device failure. Our goal is to inform both physicians and communities that chronic pain patients have not been forsaken and the doctors have not stopped caring despite their offices being closed. The new guidelines allow us to continue to care for both established and new pain patients via virtual telehealth visit. Patients with new urgent pain complaints can be triaged via telehealth and offered in-person visits after careful screening process. Established patients can followed through telehealth while protecting all of us.
The following is a primer on implementation of telehealth into an existing clinical practice.
Technical Requirements
Up to date laptop or desktop with camera (review what is behind you)
High speed internet service or comparable 4G cellular service
Recommend headset with microphone to allow for clarity and patient privacy
Built-in Telemedicine in EHR
- https://www.epic.com/ (opens in new tab)
- https://www.modmed.com/ (opens in new tab)
- https://www.drchrono.com/ (opens in new tab)
Commercial Platforms
Roundup of Telemedicine Software
Staffing & Scheduling Considerations
Virtual telemedicine visit can take 15-30 minutes. To allow for efficient workflow, support staff will make initial contact and ensure they are moved over into the virtual waiting room.
This includes ensuring the patient has the appropriate hardware to conduct the visit.
Options include in office telemedicine with support staff versus complete virtual telemedicine with providers in remote location.
Legal Implications
One must obtain patient consent from patient to conduct telemedicine visit. Many commercial telemedicine platforms already have this built in. If not you can obtain consent via prior written, electronic document, or verbal (and document). Formal consent process have been relaxed during the national emergency declaration it is still advisable to inform patients the rationale for carrying out a virtual telehealth consultation and obtain a verbal consent for documentation purposes.
Informed Consent for Telemedicine
- Video consultation may not be as complete as a face-to-face consultation.
- There may be possible technical limitations that can affect the quality of the video and audio.
- If virtual consultation does not achieve patient’s goals, you will be given options including an additional virtual visit, or face-to-face consultation.
- You may change your mind during the virtual consultation and stop.
- Having virtual consultation does not change the patient’s right to standard of care.
Telemedicine During COVID-19 Pandemic
As part of the HHS emergency declaration, the Federal 1135 Waiver, Coronavirus Preparedness and Response Supplemental Appropriations Act, practices such as ours can continue to care for patients via telemedicine.
Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020
1135 Waiver
DEA Response
https://www.dea.gov/press-releases/2020/03/20/deas-response-covid-19 (opens in new tab)
For a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
Telemedicine is conducted using an audio-visual, real-time, two-way interactive communication system.
In accordance with applicable Federal and State law.
Prescriptions may be sent out utilizing conventional means: written Rx, E-prescription, call into pharmacy.
No changes to current guidelines on duration of prescription.
Teleheath Experience
Patients will receive a notification via email or text of the appointment when the patient logs into the virtual waiting room. The clinician will then invite the patient into the virtual exam room. This requires both audio and visual connection. To ensure a complete visit experience, the provider may choose to include the medical assistant in a group chat format. The medical assistant can obtain the necessary intake information while the clinician reviews the patient’s chart. Initial intake information may include vitals (temperature, HR, BP, and RR) by asking the patient to take these measurements. The conversation is then transferred to the clinician to carry out the consultation. Clinician should utilize the video capabilities of telehealth to examine the patient. For example, patient may point to areas of the body affected or directly show their incisions. Limited physical exam may also be carried out by instructing the patient to perform maneuvers such as a straight leg raise. As the consultation comes to a conclusion, the clinician may review care plan and hand the conversation back to the medical assistant to complete any necessary scheduling of tests, procedures, or follow up appointments.
Coding & Reimbursement
Starting March 06, 2020, under the HHS emergency declaration, the Federal 1135 Waiver, Coronavirus Preparedness and Response Supplemental Appropriations Act, practices such as ours can continue to care for patients via telemedicine.
Medicare will make payments for Medicare telehealth in broader scope. Virtual visits will be reimbursed the same as in-person visits. HHS office of Inspector General (OIG) will increase flexibility for providers to reduce or waive any coinsurance and deductibles. Under the 1135 waiver, there must be an existing patient relationship.
However, HHS will not conduct audits to ensure such pre-existing relationship during the COVID-19 outbreak.
Encounter Types
There are 3 general categories of telehealth encounters:
Virtual Check-ins
- Established patient
- Brief 5-10 minute communication with exchange of information via telephone or video/image
- Patient initiated
- No prior communication related to complaint for 7 days and does not lead to visit within 24 hours
E-Visits
- Established patient
- Patient initiated
- Non-face to face communication billed in 10 minute increments, example patient portal
- Can be carried out by physician extenders
- Can occur over a period of 7 days
Telehealth visit
- Patient initiated
- New and existing patients
- Audio and visual connection
- Under 1135 waiver audio/visual connection can be non-HIPPA compliant (example FaceTime, Zoom)
- Same billing requirements and codes apply without the use of modifiers
AMA Guidance
- https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice (opens in new tab)
- https://www.ama-assn.org/system/files/2020-03/covid-19-coding-advice.pdf (opens in new tab)
Medicare Guidance
Health Insurance Portability and Accountability Act (HIPPA)
Health Insurance Portability and Accountability Act (HIPPA)
During the public health emergency, Department of Human Health Services (HHS) Office for Civil Rights (OCR) will not enforce and waive penalties for HIPAA violations by health care providers that serve patients in good faith via everyday communications such as Skype, FaceTime, etc.
Business of Telehealth
In times of global crisis, necessity become the mother of new inventions and innovations. Telehealth is hardly a new concept, yet adoption of this technology may have just been kickstarted by the COVID-19 pandemic. As healthcare professionals, our first goal is the compassionate care of patients. The global health crisis has brought new challenges of rationing of vital resources and social distancing.
Telehealth can offer a new paradigm in which we can care for patients through virtual visits. Potential upside of the telehealth movement can lead to permanent changes to the way we deliver healthcare.
Current telecommunication technology can already support telehealth. Most patients already have laptop computers and smart phones.
From a patient experience perspective, we can eliminate unnecessary wait times and provide incredible versatility to the access of healthcare.
In turn, the silver lining will be improved delivery of healthcare with better patient outcomes.
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