Telehealth — healthcare and health-related information delivered remotely through telecommunication — has been at the University since the mid-1990s, but COVID-19 has made patients and physicians alike eager to use telehealth in the era of social distancing and personal protective equipment shortages. While this improves access to patient monitoring and specialist care for some, those who cannot afford the technology are left out.
For telemedicine in general, business is booming. Karen Rheuban, co-founder and director of the University’s Karen S. Rheuban Center for Telehealth, said the sudden expansion of the telemedicine program in the University Health System, as well as sudden changes related to billing and license restrictions, has required an “all hands on deck approach.”
In 2019, the center for telehealth supported slightly more than 20,000 telemedicine visits, but mid-March through mid-May of 2020 it had 44,400 visits. Meanwhile, outpatient visits have dropped by 90 percent. To accomplish such a rapid transformation, the center deployed webcams and other hardware to the clinics, correctional facilities and long-term care facilities that it partners with. The University Health System has spent approximately $2 million to expand telemedicine within the University and for community partners.
The center also kept abreast of continual changes regarding medical technologies that are federally approved and covered by Medicaid. Rheuban has also taken on a policy advocacy role to ensure that physicians are getting paid for their care and that more patients can access telemedicine. A key part to making that happen includes working with public and commercial insurance policies to expand telemedicine coverage and reimbursement.
Before COVID-19, public health insurance had limitations on where a patient could physically be located when receiving care — called the originating site — in order for the provider to receive reimbursement for telemedicine services. Except for limited cases, like monitoring stroke and substance abuse disorder patients, care from the home was not covered — until a few months ago.
“Medicaid in Virginia on March 19 issued new rules, and they said the home was an eligible originating site, and they would also pay for telephone visits,” Rheuban said. “Suddenly, we had solutions that enabled us to ramp up the delivery of care virtually across the Commonwealth.”
Drew Harris, associate professor in the School of Medicine who specializes in pulmonary health and public health, also believes that telemedicine expands access to health, but less so in rural communities.
Harris has been working with Stone Mountain Health Services in southwest Virginia, which includes clinics that specialize in black lung, a condition common to coal miners. For over a year, Harris drove monthly to see in-person patients at these clinics. Because of COVID-19, these visits have been transferred to telehealth formats where the patient tunes in from their home or — if they do not have access to the Internet or a mobile phone signal — a local clinic.
Although patients and physicians do have to adjust to the new online dynamic, this expansion allows speciality care to be given to patients from far away, instead of them needing to drive four or more hours to receive care from the University Health System in person.
“For the most part, it works pretty well and we are able to bring specialty care to a place that has less access to it,” Harris said. “What we're all doing now in telehealth with COVID is largely talking to folks while they're in their homes.”
Within the University Health System itself, telehealth can be useful for treating highly infectious patients, according to Kyle Enfield, associate professor of internal medicine in the School of Medicine. Using a system called iSOCOMS, COVID-positive patients can be isolated in the hospital and consulted via telehealth. That reduces the amount of personal protective equipment needed and allows the patient to speak frequently with physicians and family members via webcam.
Before the COVID-19 pandemic, the University Health System only had five beds set up with iSOCOMS technology. Today, according to Rheuban, there are over 100 — a number reached as a result of the hospital not knowing how many COVID-positive patients would be admitted and wanting to be prepared. The occupancy of those rooms varies based on the number of admitted COVID-19 patients and patients from the emergency department waiting until testing is complete.
“Now it becomes all the more imperative with coronavirus, but it also enables the doctor to talk to the patient where they're not in spacesuits,” Rheuban said. “It also enables other consultants to be virtually brought into the room. That way, we're conserving personal protective equipment. We're having a more humanistic experience for the patient.”
Although the post-COVID-19 future is still nebulous, more physicians and patients are becoming comfortable with digital interactions, especially if it saves on travel time and expenses.
Certain medical procedures will still take place in person, Enfield explained, but he hopes that routine check-ups or conversations with a specialist will take place on telehealth platforms. If those interactions can happen online, then more resources can go toward patients who need to be treated in person.
“Is it really necessary for a patient in southwestern Virginia to fly to U.Va. if all that they really need is my brain?” he said. “If we can close the distance between expertise and the patients, then I think that's a place where it's good for us to continue this.”
Despite these advantages, there are still challenges. One, Enfield explained, is that not all physical procedures can take place via webcam, such as diagnosing a complex or serious illness or changing a breathing tube.
According to Harris, another challenge is that the resources available to telehealth are limited to the patient’s physical location. For example, a patient’s local clinic might not have the lab testing availability that a University specialist would recommend for that particular case.
The major barrier to telehealth that Rheuban, Enfield and Harris all pointed to is limited accessibility of technology in underserved communities. Harris pointed out that some areas near the University — such as Buckingham County — have the lowest rates of access to high-speed internet in the nation. While he predicts that more biotechnological products — like a digital stethoscope — may be available on the market to consumers and expand accessibility to telehealth, other communities will remain behind.
“The biggest challenge is that the most disadvantaged populations that don't have the appropriate bandwidth are not going to benefit from it,” Harris said. “A lot of my patients in Appalachia don't have great cell signal because it's real rural and real mountainous, and most of them can't afford to put in a WiFi signal.”
Enfield agreed and said that people who do not own computers, telephones or WiFi have a difficult time participating in the burgeoning telehealth field.
“You tell them the only way they can see their doctors is through the system they don't own,” Enfield said. “It basically forces them out of the healthcare marketplace.”
According to Rheuban, the Federal Communications Commission has programs that the University’s Center for Telehealth taps into to bring broadband to rural providers, including the Connected Care Pilot Program, which can bring broadband into patients’ homes.