PracticalDermatology

March 2020. COVID-19 has not only come to America; it is spreading rapidly. In response to calls to “flatten the curve,” and in efforts to preserve much-needed medical supplies, a majority of private medical practices around the country shut their doors. They wait, grimly acknowledging that patient health—and the bottom line—will surely suffer. Against this backdrop, the Department of Health and Human Services (HHS) issues new temporary guidance around the use of telehealth, making it easier for providers to onboard the use of two-way communication technology for health care services during the public health emergency (PHE) caused by the coronavirus pandemic, creating an important opportunity for patients to maintain access to their doctors.

The initial ruling, an 1135 waiver (named for the section of the Social Security Act that authorizes the HHS Secretary to modify or waive certain Medicare, Medicaid, CHIP, or HIPAA requirements during emergency situations), functioned to expand upon telehealth exemptions that were included in the Coronavirus Preparedness and Response Supplemental Appropriations Act. The real consequence of the waiver, though, was a loosening of red tape that previously stymied the use of telehealth. Among other measures, the limitation on using telehealth only with existing patients was lifted, the range of providers allowed to offer telehealth was expanded, Medicare dropped the requirement for patients to live in a designated rural area, and providers were now free to offer telehealth to patients in their place of residence. Some states made it permissible for providers to care for patients across state lines. The waiver, and subsequent actions by HHS, also clarified rules on coding and reimbursement for beneficiaries of programs administered by the Centers for Medicare and Medicaid Services (CMS), including the creation of telephone-only codes and the provision that doctors could bill for telehealth services at the same rate as in-person visits.

In one particularly important measure, the new set of guidance established that the HHS Office for Civil Rights would “exercise enforcement discretion and waive HIPAA violations” for healthcare providers who use communication technologies “in good faith” to serve patients. Although a somewhat nebulous declaration, the provision is actually exceedingly important for making it feasible for providers to adopt and for patients to use telehealth services. Outside of using public-facing communication services like Facebook Live, Twitch, or TikTok, providers were afforded broad discretion in selecting an application for video chats without running afoul of HIPPA requirements.

In the context of the COVID-19 pandemic, the new rules make all the sense in the world. And for a highly visual medical speciality like dermatology, where physically examining the skin is an important part of making a diagnosis and managing patients, the new guidance would seem the perfect opportunity to figure out whether telehealth offers an ability to improve outcomes. But as the pandemic wore on, and as the world transitions to a time not dominated by the scourge of a public health threat, new questions have arisen about whether teledermatology could or should be a permanent fixture.

Defining A New Normal With Teledermatology

The impetus for expanding telehealth services was born of necessity—a pandemic that called for social distancing, and, therefore, a restriction on the feasibility of in-person clinical visits. Patients still had a need to see their doctor for ongoing and new medical needs not related to COVID-19, and so telehealth seemed an optimal bridge to a new normal.

What was really unknowable at the time, however, was that the pandemic would last a lot longer than anticipated and that it would continue to impact all levels of society even beyond a return to “normal,” regardless of how it is defined. According to Ivy Lee, MD, of Pasadena Premier Dermatology, Pasadena, CA, and a member of the American Academy of Dermatology Teledermatology Task Force, legislators at both the state and federal level are now grappling with whether and how to make telehealth expansion permanent.

“Knowing that Pandora’s box has been opened, or the rules have been relaxed in the telehealth expansion laws that were issued during the initial phases of this public health emergency, the question now becomes how many of the changes that were initially implemented in March are going to be long lasting?” Dr. Lee says.

After a tremendous surge of telehealth utilization following the 1135 waiver, volume has since waned. At least some of the initial growth in use was due to previously delayed office visits, and so a decline would be expected. However, almost a year later, although telehealth visits are still greater than pre-pandemic baseline, adoption and utilization are far lower across all medical specialties than might be expected. The return of in-person visits as an option was partly causative, but other factors may have contributed.

“I think as the pandemic wore on, people started realizing how important human connections are and how important our relationships are, especially those trusted relationships with physicians,” says Dr. Lee. “When telehealth is not the only option, providers and patients started thinking about, well, we’ve used telehealth, we like it when it’s the only option, but how is it going to exist going forward?”

Answering that question may entail dealing with the devil in the details. One factor that telehealth has exposed is the true depth of the digital divide across American society. Economic disparities leading to uneven access to the Internet were somewhat well known if not fully acknowledged or addressed prior to the pandemic. Since the outbreak of COVID-19, though, as more of daily life has moved online, the effects of the digital divide across ethnic and age groups have come to light. How American society reckons with a need to create equitable experiences with respect to digital utilization is a problem beyond the scope of dermatology, but it is something that affects practitioners nonetheless. On the one hand, there are still broad swatches of society without reliable digital connectivity, and so achieving universal access remains an issue. As well, even among the connected, there exist different levels of comfort with telehealth and prominent disparities in tech acumen. And so, even if doctors choose to offer some form of telehealth, making it user friendly may present challenges.

Yet, the fact that medicine is dealing with such challenges may be a net positive. After all, according to Dr. Lee, a very challenging situation created a unique opportunity to redefine normal. In her view, now that more patients and providers have gained experience with telehealth services, the pressing question is not necessarily whether it can improve care, but how to do so.

One of the more positive developments from the expansion of online and digital services during the pandemic is a realization of how technology can be harnessed to improve daily life. The past year—and really the past decade—has seen a vast growth in online services, affecting everything from banking to dating to food ordering. Thus, there would seem to be great potential to incorporate telehealth in a meaningful way, at least as a complement to in-person visits, to help redefine normal physician-patient interactions.

“There’s a lot of room for using that in a hybrid way to complement in-person care, for patients who may not need in-person care, to offer them help at an earlier point in their disease or their concern, and to more expeditiously and effectively offer them relief, and hopefully stay well in a preventive way,” Dr. Lee says.

Grappling with Implementation

The law of unintended consequences states that there will almost inevitably be unforeseen outcomes from any change. Removing barriers to telehealth has had several beneficial results, but it has also raised new and unexpected questions. For instance, removing the restriction of using telehealth only with pre-existing patients has proven to be a double-edged sword: patients have gained greater access to providers, especially specialty care, but establishing trust over digital platforms is inherently different, and whether effective working relationships can be established may depend on circumstance. According to Dr. Lee, physicians may need to rethink how they present themselves on digital media to convey empathy and establish a connection. Conducting a telehealth consult may also require a different tactical approach compared to in-person visits, with more time dedicated to building the history.

Regardless of how fraught with new complexities this new normal may be, though, the benefit of expanded access to specialty care outweighs the negatives. Especially in complex cases, telehealth may serve as an opportunity to build a team-based approach to care.

“With the newer patients, I can tell you that oftentimes I’m working with a referring provider to manage a patient’s skin condition. That works really well because we’re part of that team. I don’t necessarily have as strong of an individual relationship with the patient, but I do have a really great working relationship with the referring provider,” Dr. Lee says. “In those scenarios, it can be very gratifying for the patient, knowing that their primary care doc has easy access to a specialist like me, and it’s very fulfilling for me because I know that if there’s any concern or if there’s any challenge for the patients, that I have an open line of communication with their primary care providers.”

George J. Hruza, MD, MBA, FAAD, of Chesterfield, MO, also notes a stark difference in using teledermatology with new versus established patients in his practice. Primarily, the challenge was in building rapport over a teleconference call with patients new to the practice. Additionally, he found that patients didn’t always seem comfortable with the medium and that the perception of value from the interaction may be different than an in-person consultation. While those are all anecdotal impressions, it is also difficult to get a real read on the situation when the patient is not in the same room. On a more tangible level, the nature of a digital consult and the challenge of implementing teledermatology amidst a pandemic certainly raised questions about the quality of care Dr. Hruza felt he could deliver.

Dr. Hruza, a past president of the AAD who worked closely with the academy’s ad hoc COVID-19 task force to establish teledermatology waivers, was originally very optimistic about what telehealth might offer. Slowly and over time, that impression soured, with several factors playing a role. For one, telehealth was never going to be a natural fit in a surgical practice—Dr. Hruza mostly performs Mohs but also some cosmetic procedures. Telehealth therefore might save a visit here and there, but at some point, the patient will be entering the clinic. Nevertheless, he started offering virtual pre-surgical consultations shortly after the waiver was announced because patients expressed concerns about coming to the office. However, because he works mostly with an older patient population, and one that is generally not tech savvy enough to make telehealth plausible, Dr. Hruza estimates that telehealth visits performed in the past few months have been more time and labor intensive than regular clinic visits.

In some instances, there were difficulties establishing a connection, sometimes requiring two or three attempts to actually connect. Even when that process went smoothly, the video connection was often inadequate to actually examine the skin. Some patients had difficulties working the camera on their phone. Even when pictures were sent in advance, they were often out of focus, shot at the wrong angle, or worse, showed the wrong skin site. Because the platform used for the interaction was not integrated with the electronic records, there was a need to manually take notes and then transcribe them later, leading to data loss on top of the redundant need to record the same information twice.

Growth in telehealth in 2020 did not offset the overall drop in in-person visits.
Source: IQVIA Medical Claims Data Analysis, 2020 Reported by Peterson-KFF Health System Tracker, www.healthsystemtracker.org , See terms here: https://creativecommons.org/licenses/by-nc-nd/3.0/us/deed.en_US

“And then what I found out was when the patient then came in for surgery, just about every case, for some reason, the information we had was incomplete. We very often did not have the information that we needed. We almost always had to do the consult again when the patient came in for a procedure,” Dr. Hruza says.

The format of how telehealth is used might be a significant factor in its success. Dr. Hruza was using synchronous telehealth, or live, interactive visits where both the doctor and patient are able to communicate over a two-way platform. Although this form is a reasonable facsimile of an actual patient encounter, without the right technology, or if one or both parties are limited in technological know-how, the result can be frustrating. Meanwhile, asynchronous telehealth (also called store-and-forward), where the patient sends information that the doctor reviews at a different time, is far more forgiving and easier to use—albeit, at the sacrifice of being able to see information and interact in real-time.

Ultimately, synchronous telehealth proved too wonky and cumbersome, and Dr. Hruza stopped offering virtual consults, although he is thinking about bringing it back in a different form for patients who travel a long distance. Regardless, out of that experience, Dr. Hruza did adopt a modified form of asynchronous telehealth where patients will send photographs during the postoperative period. While not always a reimbursed service, it has nonetheless proven useful as a quick triage and has the effect of limiting unnecessary patient visits during the pandemic.

That whole experience may be somewhat emblematic of the entire trial run with teledermatology during the pandemic—it worked better for some practices than others, and the harried nature of integration, although necessary, also exposed some of the flaws with telehealth as it is currently conceived.

“I think it just didn’t work well for my practice. It was the kind of practice I have, the patient population age and the fact that I still have to anyway see them in person. But I think teledermatology does have value. I think it’s good,” Dr. Hruza says. “For example, acne patients that you’re seeing, for them to come in every month so you can look at their skin and then say, well, we’re going to adjust this med or that med—I think that is very well managed through teledermatology, or psoriasis patients or eczema patients. And I think it can be very useful there, and dermatology as a specialty does lend itself naturally to digital interaction, as long as you get good images.”

Teledermatology in the Post-Pandemic World

The prevailing sentiment around teledermatology, at least for now, seems to be that when remote consultations were the only option, the waiver system provided the perfect opportunity for dermatologists to continue to serve patients. However, since the return of in-person visits, interest has waned significantly, which may be a consumer-driven mindset more so than one driven by providers, even if niggling issues over implementation continue to exist.

Brian Zelickson, MD, a dermatologist in Minneapolis, estimates that use of teledermatology in his practice dropped sharply from a high of around 90 percent in the early days of the pandemic to about five percent currently. It is still be offered, but patients are not inclined to use the service.

“I just think people would rather be seen,” Dr. Zelickson says, referring to in-person visits.

Dr. Zelickson says he ran into many of the same issues as other dermatologists interviewed for this article: connectivity was spotty, image quality was often insufficient to examine the skin, and as a consequence, consults were longer and more difficult to manage than regular clinic visits. At the same time, the convenience factor associated with teledermatology is something that patients have not conveyed a willingness to take advantage of since social distancing guidelines have been relaxed.

“For certain populations, I think there’s certainly going to be a need for it. But in my opinion, from my experience, from what we’ve seen, when it was the ideal, we couldn’t have asked for something better to push teledermatology than what we’ve been through the past 10 months. The proof is in the pudding for me. People would rather come in,” Dr. Zelickson says.

It may be the case that the concept of teledermatology currently outpaces the ability to use it effectively. As technology gets better, as more populations gain acumen with using smartphones, computers, and other digital media, there may be a bigger push from medical providers, and perhaps a greater demand from patients, to offer telehealth. Yet, there is an important caveat that may ultimately determine whether dermatology is a suitable subspecialty for telehealth services. “I suppose if they do give reasonable reimbursement,” Dr. Zelickson offers.

There is one additional, and exceedingly important question that remains to be answered: Does teledermatology have any impact on the quality of care delivery? Was it merely a substitute for clinical visits during an extraordinary period of history, or is there value in offering telehealth on a more sustained basis, where it can replace or augment in-person visits?

According to Dr. Lee, it may too early to fully answer that question. Reimbursement parity was a good thing, and the private insurance market has largely followed suit, with many payors actually going above and beyond the statutory loosening of restrictions applied to public insurance offerings. In some sense, the experience gained during the pandemic was a demonstration project, a trial run, with the use of two-way communication technology for health care services. To what extent telehealth becomes a permanent fixture in medicine, whether private and public payors will push for more lasting reimbursement parity, and whether consumers drive demand, will hinge on what the numbers say about outcomes of digital interactions between patients and providers.

“We looked at the numbers and the numbers were that a lot of people used telehealth. Now what we need to do is go through that data and look and see, do these patients do well with telehealth? Did it replace the need for in-person visits or did it add on additional visits? So is it substituted or supplemental in terms of in-person visits? And that will determine kind of how I think private payors and CMS will continue to support telehealth through reimbursement and regulation,” Dr. Lee says.