​ Information Technology

A telemedicine check-up

A look at some survey data

By David Holt, JD

elemedicine use has expanded rapidly across the United States, largely due to pandemic-related necessity and the challenges posed by in-clinic visits. President Donald Trump declared a national emergency on March 13, 2020, and the Centers for Medicare & Medicaid Services (CMS), Minnesota health agencies, and professional boards quickly moved to loosen restrictions and issue “waivers” for compliance with telemedicine guidelines. Following Minnesota Gov. Tim Walz’ Emergency Executive Order 20-01 declaring a peacetime emergency related to COVID-19, the Minnesota Commissioner of Human Services was granted temporary authority by the Governor to waive or modify certain requirements in order to provide essential programs and services during the pandemic, and the Legislature enacted several laws. This article will look at some of the challenges and benefits from Minnesota’s experience with telemedicine thus far.

Pluses and minuses

The benefits and drawbacks of telemedicine quickly became apparent as some medical providers were forced to quickly adopt telemedicine to keep their practices running. More data is accumulating rapidly, since the COVID-19 pandemic introduced many Americans to telemedicine for the first time. In 2019, in the pre-COVID-19 world, a telehealth study noted that while 9.6% of Americans had used telehealth services, nearly three-fourths (74.3%) said they either don’t have access or are unaware of a telehealth option, according to the 2019 J.D. Power Telehealth Satisfaction Study (https://tinyurl.com/mp-jd-power). Unsurprisingly, patients 65 years old and older—among the populations at highest risk from the virus—were less likely to use telemedicine, representing the lowest utilization rate of any age group (5.3% of those surveyed).

​For minority patient populations, there is a larger gap in access to telemedicine technology.

The main benefit during the COVID-19 pandemic, of course, is that patients can continue to receive medical care from the comfort of their home without risking exposure to COVID-19 during an in-office visit. Another benefit of telemedicine is the increased access to providers, when distance and geography are eliminated as a barrier. When the telemedicine laws were first passed across the country at the state and federal levels, lawmakers emphasized that telemedicine would increase access to care to rural communities. One limitation of this benefit is that the rural expansion of telemedicine generally relies on a stable internet connection, which is not always reliable. This may not all be about the delivery methods, but rather an awareness issue. Awareness of telemedicine was lowest in rural areas, where 72% of respondents were unaware of telemedicine as an option.

Not all telemedicine services require an internet connection. Some services are delivered through a simple phone call, but this, along with other electronic delivery modes, is still subject to HIPAA requirements. The Office for Civil Rights (OCR) at the federal Department of Health and Human Services (HHS) has issued guidelines for compliance with patient privacy laws (https://tinyurl.com/mp-hhs-ocr). During the COVID-19 National Public Health Emergency, patients and providers may use popular apps that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype, to provide telehealth without risk that OCR might impose penalties for noncompliance with HIPAA. In addition, Minnesota modified state telemedicine guidelines to include phone calls for eligible providers who render services via telemedicine and can demonstrate that it is safe to do so. (See the Minnesota Healthcare Programs Provider Manual’s webpages on “Telemedicine” and “COVID.”

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Also, to account for the increased frequency of telemedicine visits, the current limitation of three telemedicine encounters per week is suspended in Minnesota. And finally, much to the delight of physicians working from home, when delivering telemedicine—including via telephone—the distant site (provider’s location) can be the eligible provider’s home. The originating site (patient’s location) can be their home. This is a large departure from previous restrictions.

Across state lines

Rural areas are not the only beneficiaries of elimination of geographic barriers via telemedicine. Providers may, in some cases, work across state lines, creating a new legal maze to determine which services are covered based on patient and provider locations. Beginning on March 6, 2020, Medicare started to temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country. It also removed the telehealth stipulation that telehealth in rural areas can only be provided with specific audio-visual equipment.

Minnesota law generally provides that a physician licensed in another state can provide telemedicine services to a patient in Minnesota if their license has never been revoked or restricted in any state; they agree not to open an office in Minnesota, meet with patients in Minnesota, or receive calls in Minnesota from patients; and they register with the state’s board. These requirements do not apply in response to emergency medical conditions, if the services are on an irregular or infrequent basis, or if the physician provides interstate telemedicine services in consultation with a physician licensed in Minnesota (MN Stat. § 147.032). All providers using telemedicine are held to the same standards of practice and conduct that apply to the provision of in-person services (MN Stat. § 147.033).

​Rural expansion of telemedicine generally relies on a stable internet connection, which is not always reliable.

Minnesota physicians are also exploring whether they can practice telemedicine with patients outside of Minnesota. Each state has different regulations, which are monitored by the Federation of State Medical Boards (see https://tinyurl.com/mp-state-regs). This is largely a state-by-state consideration and may implicate laws outside of Minnesota.

Patient and physician feedback

One drawback to telemedicine is that some patients report that the two types of “visits” are not the same. A remote telemedicine visit will never be exactly the same as an in-office visit, and that is a concession all providers make in adopting telemedicine technology. Nearly half (48.7%) of patients in the J.D. Power study believe that the quality of care received in a telehealth session is lower than that of a doctor’s office visit, while only 6.2% perceive the quality to be higher, and 45.1% believe it to be the same. Another 43% also believe a telehealth session to be “less personal” than an office visit. The metrics to measure “quality” are certainly up for debate, but a large percentage of patients do report a difference in service.

As another drawback, primary care providers in community health clinics in Minnesota are reporting difficulties faced by older patients and those who are unfamiliar with telemedicine technology—which often includes downloading some sort of application onto an electronic device. Melvin Ashford, MD, of Minnesota Women’s Care P.A., reports that “Elderly patients do have issues with the technology. Thankfully as of now they allow non-video options. For elderly patients we simply use a phone call. Telehealth will be helpful in extending expert help to other surgeons during surgery but can never replace procedures.”

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There are additional barriers for low-income patients and minority patients whose preferred language is not English. Robert Larbi-Odam, MD, of Community Care Clinics, reports that there is an additional cultural barrier with performing any in-person visits and using telemedicine with certain minority populations. For minority patient populations, there is a larger gap in access to telemedicine technology and larger misconceptions about COVID facts, reporting, and treatments. Ayan Abukar, CEO of Actioncare Community Clinic, echoes this sentiment, stating that the Somali-American population, especially older patients, prefer in-person visits, which is hindered by any widespread adoption of telemedicine at her clinic.

Summary

The COVID-19 pandemic introduced many Americans to telemedicine for the first time, so more data continues to be gathered at a rapid pace. The J.D. Power study noted that while 9.6% of Americans have used telehealth services, nearly three-fourths (74.3%) say they either don’t have access or are unaware of a telehealth option. In addition, patients aged 65 and older were less likely to use telemedicine—maintaining the lowest utilization rate of any age group surveyed (5.3%).

Lawmakers and stakeholders in telemedicine are already discussing what comes next. Will the relaxed regulations stay? Should a national telemedicine law be passed? How do we learn from the benefits and drawbacks of telemedicine to navigate a post-COVID world? As Dr. Ashford notes, “Medicine was already becoming national and regional with patients traveling across state lines to visit with providers offering services not available in their area. This [telemedicine offering] will increase dramatically with enhanced options and patient acceptance. This also will have a positive impact on the health of homebound elderly patients and other populations with limited access to care.”

David Holt, JD, is a Minnesota health care attorney practicing at Holt Law LLC.