Telehealth in Vermont
COVID-19 Response & Recovery
Recent Site Updates:
- Added new review of studies related to audio-only telemedicine & telehealth in Planning for the Future. 2/20/21
- Added NYS Telehealth Training portal to toolkits section. This is for NY but check it out and imagine having our own VT version. 1/13/21
- Noted in Reimbursement that Cigna's new virtual care policy took effect 1/1/21. DFR has clarified that Cigna will honor VT claims following VT guidance (which is more expansive than the new policy)
- Added link to the VT COVID-Response Telecommunications Plan (finalized 12/20) and an overview of Federal supports for broadband access (created 1/4/21).
- Note: FQHCs and RHCs, there is updated guidance on telehealth cost share as of 12/3.
- Vermont Department of Financial Regulation report on reimbursement for audio-only telehealth, 12/1. [This link currently down due to site updates]
- CMS' Final Physician Fee Schedule rule released, 12/1.
Brief Introduction & Definitions
Want an introduction in podcast format? Check out Policy in Plainer English Season Two - Telehealth in the Time of COVID-19
Feeling overwhelmed and looking for a structured introduction to all of telehealth? Try Telehealth Bootcamp - you can also refer to this Telehealth Readiness Assessment from NETRC, and this Telehealth Refresher slide deck from the VPQHC/NETRC office hours (11/18/20)
Telehealth covers a broad range of tools that allow providers and patients to communicate without being in the same place. One particular form received a lot of attention during COVID-19; replacing in-person office visits with visits done over a video conferencing platform, something like Zoom. That’s. . . really a small piece of it, before pandemic times that form of telehealth wasn’t even considered terribly interesting. Telehealth includes everything from using common devices like a FitBit to develop healthy habits up through connecting rural emergency departments with larger teams working in a remote tele-command center (even the New Yorker noticed).
This toolkit is focused on the basics of telehealth entering, and exiting, the COVID-19 public health emergency (PHE) so we won’t get too far afield. It bears noting, however, that we’re addressing one aspect of telehealth and not the whole thing.
Quick vocabulary clarifications for understanding what is discussed in this guide -
- Federal Definitions of Telehealth - just in case you wanted to get formal, here’s a link. And here's a link to a research paper explaining why the preceding link will be hopelessly confusing. Please note that Medicare uses “telehealth” and “telemedicine” in reverse of what everyone else says. The reason why is buried somewhere in Area 51. We might want to look to a source other than the federal government for clarity. . .
- Telemedicine is live, audio-visual, interactive consultations between provider and patient. Every state has rules in place allowing telemedicine, although those rules may be different from state to state. Vermont has parity coverage and parity payment for both medical and dental telemedicine services.
- Telehealth is a broader term encompassing telemedicine and other services such as store-and-forward (asynchronous communications, for example eConsults) or remote patient monitoring. At a state level telehealth reimbursement was quite limited prior to COVID-19, while Medicare had relatively more permissive rules in this category - often to encourage more active management of chronic conditions.
- Brief Telecommunications (sometimes called triage communications) often mean phone calls but aren’t limited to the telephone. What makes them triage is that they aren't connected to a following E/M service, they're used to determine if someone needs medical attention that requires more than a 5-10 minute conversation. Medicare reimbursed these prior to COVID-19, Medicaid had some options, for many Commercial payers this is new.
- “Audio-only telephone” in this guide, we're using this term any time a payer opens up an audio-only option for providing telemedicine specifically to deal with COVID-19. In some states those rules have since become permanent. To confuse matters further, there were also some audio-only codes prior to COVID-19 that existed somewhere between telemedicine and telehealth. For example, CMS often describes 99441-99443 as a special category of ‘audio-only’ introduced for the emergency, whereas for VT Medicaid those were pre-existing codes. Confusing things further, at the Federal level pre-COVID you could not use a phone to access telemedicine, even if it had A/V capabilities (that was waived for the emergency). Then there's also just "telephone-based services", for example implementing a chronic care management plan that calls for monthly check-ins with providers (that's telehealth). Do you see why some people do not like rules that specify particular platforms / devices and instead prefer technology neutral regulations? Yeah. To recap, in this guide, "audio-only" means telemedicine delivered without use of video.
If you are looking for some more basic introductions to telehealth, the National Consortium of Telehealth Resource Centers offers this short “framing telehealth” overview of definitions, and the Northeast Telehealth Resource Center has this Telehealth 101 handout (both are pre-COVID-19).
Vermont had telemedicine prior to COVID-19 and will after COVID-19 For Vermont Medicaid and for Commercial Payers
- Telemedicineis covered at parity to in-person visits.
- Vermont does not have restrictions on locations for provider and patient, this includes recognizing the home as a patient location. Note: There are rules if there's a state line between patient and provider, see the Licensure section for details.
- Vermont does not restrict the types of services (if medically appropriate) or types of providers who can provide telemedicine. Starting July 1, 2020, Vermont also does not restrict the types of providers who can provide store-and-forward services.
- Telemedicine parity under COVID-19 was extended to include audio-only telephone options, see individual plans for how to code for this system. This is a temporary change. However, some systems may have individual codes that include telephone as an acceptable platform, for example Medicaid 99441 - 99443. These tend to pay much less than audio-visual.
Medicare had telemedicine (which they call “telehealth”) prior to COVID-19 and will after COVID-19 But it had many more restrictions than Vermont. At the time of this writing, Medicare has indicated that they anticipate a significant expansion of telehealth exiting the COVID-19 emergency. We are adding new announcements regarding these changes to the Reimbursement section, and will update all sections when there is a major change to the system:
- Medicare prior to COVID-19 had a more robust list of virtual services that do not replace an office visit than many other payers - options such as remote patient monitoring, brief telecommunications, online patient portals, chronic care management, and interprofessional consultations.
- Medicare prior to COVID-19 had a published list of service codes that can be provided via telehealth and a short list of providers who could deliver them. As of April 30th they have expedited the process of adding individual codes and opened the list of providers who could bill telehealth.
- Medicare has added audio-only options during COVID-19 this is done both by listing individual codes as having “audio-only” option and reimbursing specific codes that always designated services over a telephone: 99441-99443 and 98966-98968.
- Restrictions on geography (urban/rural) & location (clinical / non-clinical) existed prior to COVID-19, but have been waived during COVID-19. Note that some of these restrictions were previously waived through participation in a Next Generation ACO (in Vermont, that is OneCare Vermont).
- FQHCs/ RHCs were not allowed to bill as providers of telemedicine prior to COVID-19 but now they have a temporary waiver to do so. This is referred to as a distant site waiver - a 'distant site' is where the provider is located, while an 'originating site' is where the patient is located.
See the Reimbursement sections of this toolkit for more information. The important takeaway is that telehealth and telemedicine existed prior to COVID-19 and the options available for performing these services will certainly expand exiting the public health emergency.
[page last updated 7.2.2020]
An overview of what changed during COVID-19 - we do not know exactly what of these changes will be made permanent yet, but we will track that progression. Updates will be added in the relevant sections by payer type below.
Many (not all) the federal changes are tied to the HHS Declaration of a Public Health Emergency, which can only be issued in 90-day increments and then must be renewed. The best source for following federal reimbursement policy for telehealth is the Center for Connected Health Policy. By a long shot they’re the best - if you’re only here for federal telehealth reimbursement policy, stop reading this guide and go to CCHP.
In Vermont, flexibilities were initially tied to the Governor’s public emergency declaration. The Legislature changed that connection to set a calendar date-certain to prevent disruptions in the event the emergency declaration ended earlier. Most of the reimbursement flexibilities are now linked to a June 30, 2021 deadline. This adjustment provides a full legislative session to decide what changes to make permanent. The Department of Financial Regulation led a working group to recommend next steps on audio-only reimbursement (full report is found here) that concluded the best solution would be to lock in parity for some amount of time exiting the public health emergency for the sake of stability, then transition to a value-based model.
A special note for FQHCs - the Northeast Telehealth Resource Center (NETRC) has developed a tailored toolkit with guidance for VT & NH FQHCs establishing telehealth revenue plans that can extend beyond the COVID-19 emergency, found here.
Important changes during COVID-19 included:
- Adding audio-only options for telemedicine services with parity in reimbursement. This includes dental codes.
- Adding brief telecommunications codes (G2010, G2012, G0071).
- Waiving requirements for an established patient relationship.
Two policy changes that came into effect during the COVID-19 emergency, but are not in direct response to the emergency and will be permanent:
- Adding interprofessional consultations for a range of professions (previously restricted to dermatology and ophthalmology).
- Codifying payment parity for telemedicine services (it had been common practice prior to the statutory change).
If you’re interested in how this fits into the national context, the Center for Connected Health Policy tracks state-based telehealth rules across the country. Here is an infographic summarizing the state rules & Medicaid trends for Fall 2020 and here is the full report.
The Vermont Department of Financial Regulation (DFR) has the power to issue emergency telehealth coverage rules through June 30, 2021 (will be extended if the public health emergency is extended). Note that this applies only to health plans issued in Vermont and it does not cover self-funded plans, so checking individual commercial plan coverage is still required.
Key features of the DFR emergency rule:
- Covering audio-only telemedicine to the same extent as a plan would cover in-person encounters & traditional telemedicine. This includes services that would be covered in the home by home health agencies.
- Providing the same reimbursement rate for services billed using equivalent procedure codes and modifiers regardless of whether they were delivered remotely or in-person.
- Covering the same number of remote consultations as for in-person.
- Removing “existing patient” rules for telemedicine. This clause may be required for the brief telecommunications, commercial payers strongly prefer onboarding new patients through a virtual office visit, such as 99201-99202.
- Covering G2010 and G2012 - brief telecommunications unconnected to an office visit (by phone or by image / video transmission) - without any cost share.
- Moves up the deadline for implementing reimbursement for tele-dentistry and store-and-forward (think eConsults between providers) to May 1.
- Reiterates HIPAA compliant platforms being non-enforced during the emergency, mental health payment parity, and that there will be no restrictions of services based solely on patient location.
DFR is currently leading a work group to develop a plan for more permanent audio-only telemedicine coverage, their report is due to the Legislature on December 1, 2020.
Because we are still in the Public Health Emergency (PHE), this section focuses on temporary Medicare rules. We also include the former structure for Medicare telehealth reimbursement, and notes on new rules that will take effect after the PHE for context. We will not truly know the landscape of post-PHE federal telehealth until Congress considers the many bills before it that propose updates to the statutes that underlie CMS decision making.
The Center for Connected Health Policy tracks federal reimbursement for telehealth services, and keeps a regularly updated chart online. This chart provides a full overview of all the changes made during COVID-19. There are a lot of them.
The Medicare response to telehealth during COVID-19 has evolved over time. To see a timeline of key decision points, refer to this earlier Bi-State summary. Some key changes include:
- Allowing FQHCs & RHCs to be providers of telemedicine (also known as ‘distant sites’). The payment for these services is bundled under the code G2025 and reimbursed at an average of the physician fee schedule ($92.03 - much less than parity to the normal PPS rate). Among the interesting features of G2025, it allows for billing non-FQHC services if they are approved telehealth services.
- Expanding the list of approved telehealth services, approving some of these services for audio-only, and streamlining the process for expanding permissible services to deliver via telehealth.
- Adding codes 99441-99443 to “telehealth services” and increasing their reimbursement rate to create a general audio-only option.
- Allowing all providers qualified to bill Medicare to bill for telehealth services.
CMS has started to release permanent changes to telehealth options. While it should be noted that these are often presented as “in response to COVID-19”, CMS has steadily expanded telehealth every summer. CMS still requires Congressional action before having the authority to fundamentally alter and expand the framework of telehealth under Medicare. Below are recent CMS actions plus some articles helping frame what is happening:
- Timeline of Federal Changes during COVID-19 Response (9/14/20)
- Final Rule on Physician Fee Schedule from CMS (12/1/20) - key changes include adding a third category of telehealth service code expansions that will remain through the end of the calendar year in which the PHE ends, adding a code that allows clinical social workers, psychologists and OT / PT / ST providers to perform brief remote clinical evaluations, and extensive clarifications to remote patient monitoring. CMS will add a permanent audio-only option of 11-20 minute evaluation to determine if an in-person visit is necessary. The permanent cap on frequency of telehealth services to patients in nursing facilities has been adjusted from 30 days to 14 days (the original proposal had been 3 days).
- Detailed summary of CY2021 Medicare Physician Fee Schedule from Center for Connected Health Policy.
- Brief Summary of CMS Final Rules - Foley & Lardner, LLP (12/2/20).
- Home Health Agencies are now permanently able to use telehealth, including audio-only, as part of an approved care plan (10/29/20)
On November 16th, 2020, Healthcentric Advisors, the New England Quality Payment Program Support Center, published an updated guide to billing Medicare for telehealth services.
On April 10, DVHA (VT Medicaid) posted guidance for billing dental services provided through telemedicine and via audio-only telephone during the COVID-19 emergency, available here.
On July 1, Medicaid also started reimbursement for store-and-forward consultations across all professions, including dentistry.
May 1 was the deadline for all commercial dental insurance plans in Vermont to offer coverage for teledentistry (this is permanent statute, not temporary rules for COVID-19).
Alternative Payment Models
Alternative payment models, and in particular capitated payments and global budgets, are often held up as the ideal option for telehealth reimbursement. By breaking from traditional fee for service, these systems lend themselves to expanding telehealth that is not a direct replacement for in-person services - for example taking advantage of tools for continuous monitoring, data analysis, and frequent provider check-ins like with chronic care management. Alternative payment models are also often used to encourage innovation at the provider level while controlling financial risk for the payer. Even before the pandemic, Medicare allowed significantly more telehealth flexibility to practices participating in Next Generation ACO models.
The problem with alternative payment models is that right now the reimbursement debate is how to keep telehealth services available coming out of the public health emergency. If you didn’t have a fully implemented APM going into the emergency, then chances are good it won’t magically appear at the end of the emergency to resolve all telehealth concerns. Nonetheless, it is a still a goal many regions are working towards. Here are some resources on this issue:
- Policy in Plainer English - Telehealth and Global Budgets
- Health Affairs - Establishing a Value-Based ‘New Normal’ for Telehealth, 10/8/20 (sadly this is both very comprehensive and also only available to Health Affairs subscribers)
- Telehealth Reimbursement Just for Value-Based Providers Post-COVID? - 9/11/20. Note that this was a point in time report on a MedPAC meeting, not a final answer.
- National Association of ACOs’ policy principles on telehealth following the public health emergency
For a Vermont-specific take on this conversation, the Department of Financial Regulation led a working group to consider future reimbursement for audio-only services that also reached the conclusion that value-based alternative payment models would need to be the answer. The full report was submitted to the Legislature on 12/1/20. And lest you think that Vermont simply accepted what the national health care economists said, believe us when we say that we closely and aggressively questioned their assumptions . . . and then agreed. More or less graciously.
[page last updated 1.13.2021]
The Vermont Office of Professional Regulation has posted information on their site regarding licenses, crossing state lines, returning to work if you have recently retired, and a guide to whether you need a temporary license to work in Vermont in the public health emergency.
First rule of telehealth licensure: it’s the patient location that matters, that is where providers need to be licensed.
During COVID-19, health care professionals, including mental health professionals, who are licensed, certified, or registered in good standing in another jurisdiction can provide telehealth services to a patient in Vermont. If there is a provider who was commuting to Vermont from outside the state, they can provide health care to their Vermont patients from home without license issues. Similarly, if your partner hospital is in a bordering state and you need a specialist to see a Vermont patient remotely for a consult, that is also allowed. The Vermont Office of Professional Regulation has posted details here.
We also need it to go the other direction. For Vermont-licensed providers to treat patients in their homes, or traveling, in other states they need to be cleared in that state. The Vermont Board of Medical Practice site has a guide to our bordering states’ emergency rules. Most have a temporary way to practice telehealth without being fully licensed in that state but the details around how that happens change by place, so please check. The Federation of State Medical Boards tracks the emergency rules in each state.
If you are working in another state, you must follow the regulations of that state. For example, non-Vermont providers practicing telehealth with patients located in Vermont should review our rules for use of the Vermont Prescription Monitoring System, Prescribing Opioids for Pain, and rules on Telemedicine and MAT.
Additional Related Rules
As part of the national emergency declaration, CMS allows reimbursement for Medicaid and Medicare to out-of-state providers working across state lines.
Note that for those working across international borders - licensure is often very different if you are a provider going into another country. If a provider is located in another country but licensed in Vermont and working with patients in Vermont, Medicare and Medicaid will not reimburse that international work, but BCBSVT and MVP will. However they caution to check that malpractice insurance covers that international work.
On the issue of credentialing, the Department of Financial Regulation posted this emergency rule update on March 20:
DFR filed emergency rule H-2020-01-E in response to the State of Emergency declared by the Governor of the State of Vermont on March 16, 2020 regarding the outbreak of COVID-19. The purpose of this emergency rule is to relax provider credentialing requirements in order to facilitate the reimbursement through commercial insurance during the State of Emergency for health care services provided by physicians or other health care professionals who hold an equivalent license in another State.
DVHA has also eased provider enrollment restrictions.
Recent changes at the federal level make virtual supervision more feasible for providers who are not licensed to work independently, as described in this CMS waiver document under workforce flexibility. Vermont OPR has provided this additional guidance for virtual supervision of Mental Health practitioners.
Licensure Issues Beyond COVID-19
In Vermont the Legislature has set a calendar date for the COVID-19 telehealth licensing rules, they will last until at least March 31, 2021, even if we exit a declared public health emergency. In other states the rules expire with the end of the public health emergency, in some states policymakers are working on systems for ongoing flexibility. Again, it is important to check each state.
The ability to work across state lines will be a topic of debate for telehealth exiting the public health emergency.
Business As Usual health care providers with a robust telehealth practice have been getting licensed in multiple states, and some are even in the club of holding a license in every state. The cost-benefit on this approach strongly favors practitioners who are choosing telehealth as their primary business model over those who simply want to reach an existing patient from their in-person practice, which is why conversations have begun about other options that make telehealth more accessible.
Without getting into the pros and cons, some of the proposed long-term solutions exiting emergency orders include:
Interstate Licensure Compacts that expedite licensure in participating states. Examples:
- Interstate Medical Licensure Compact (Physicians)
- NLC (Nurse Licensure Compact) and APRN (Advanced Practice Registered Nurse) Compacts are hosted by the same organization. This is the largest and oldest interstate licensure compact.
- PSYPACT (Psychology Inter-jurisdictional Compact)
- Physical Therapy Licensure Compact
- Recognition of EMS Personnel Licensure Interstate CompAct (REPLICA)
Note that every compact works on its own rules, some are reciprocal and some simply open up expedited options for gaining a license.
Federal Licensure Portability Support Program - a grant program to facilitate these compacts in support of telehealth (see page 8 on this FAS federal telemedicine summary)
State Legislation - State boards of medicine in 11 states issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine. Those states are AL, LA, NV, NJ, NM, OH, OK, OR, PA, TN, TX.
Florida built out-of-state doctors’ options directly into its telehealth laws.
Federal Law Designating Provider Location as Place of Service Currently the patient’s location is the ‘place of service’, however changing the location to travel with the provider could resolve the issue of patients attempting to access their primary provider when they are not, themselves, in their typical location.
The Brookings Institute explains it this way:
Another solution would be a federal law that designates the provider’s location as the location in which care takes place for the purposes of licensure and payment. This would preserve the authority of state medical boards to grant licenses, while allowing physicians to treat patients remotely in other states. (Report on Regulatory Barriers to Telehealth)
The Bipartisan Policy Center recommends a similar approach:
Congress should pass legislation authorizing licensed providers in a state to provide services to Medicare beneficiaries in another state. Moreover, for the purposes of providing telehealth in rural areas or HPSAs, services should be considered to have been furnished at the location of the provider, or distant site, rather than the patient, or originating site. This should apply to matters of both licensure and liability. Although members of Congress introduced two bills to accomplish this (S.2662 and H.R. 3077) in the 113th Congress, neither passed. The Telemental Health Expansion Act of 2019 (H.R. 5201) and Mental Health Telemedicine Expansion Act (H.R. 1301) would remove the site restriction but would not address non-mental health services (from “Confronting Rural America’s Health Care Crisis”)
For more information on licensure and interstate telehealth, check out the recording of the July 15th telehealth office hours on this topic, hosted by VPQHC. The introductory slides are linked here.
Or, if you want to see the real professionals (aka lawyers) take on the licensure subject, we highly recommend this webinar from the National Consortium of Telehealth Resource Centers (11/10/20).
[page last updated 11.16.2020]
Patient Consent to Telehealth Services
During COVID-19, some of the rules around patient informed consent to receive telehealth services have changed. However, that is only true if it is not feasible to implement - best practices is still to receive informed consent. These rules are designed to ensure patient clarity around what can be a confusing new form of health care. Therefore, while nobody wants bureaucracy to limit health care access during COVID-19, we recommend learning the underlying rules and implementing as much as possible.
Vermont recognizes electronic signatures - this pre-dates COVID-19
“Electronic signature” means an electronic sound, symbol, or process attached to or logically associated with a record, and executed or adopted by a person with the intent to sign the record.
For the purposes of gaining informed consent for telemedicine, Vermont offers both oral and written options:
A health care provider delivering health care services through telemedicine shall obtain and document a patient’s oral or written informed consent for the use of telemedicine technology prior to delivering services to the patient. 18 VSA §9361(c)(1)
Many online platforms designed for telehealth have already built in options for signing electronic forms. During COVID-19, if you are using a verbal consent to telehealth treatment and billing, do not forget to record this agreement in the health record.
Sample Consent Forms
These sample forms predate COVID-19. Below we flag some of the items that were a standard part of informed consent for telehealth that have been adjusted in COVID-19:
- UVMMC Patient Consent Form for Telemedicine
- Agency for Healthcare Research and Quality (AHRQ) - "Easy to Understand" consent form template
- AHRQ Template Adjusted for Vermont
- Sample Forms from California Telehealth Resource Center
- Blog post on Telemedicine & Informed Consent from Southwest Telehealth Resource Center.
If you are creating your own consent form, note that Vermont is specific about what needs to be covered, listed in 18 VSA §9361(c)(1), and in greater detail in the Medicaid administrative rule, section 3.101.5.
For a conversation with Vermont practices on how they’re currently implementing informed consent, check out the recording of the June 10 VPQHC office hours discussion with Dr. Mark McGee.
Key Changes During COVID-19
Act 91 temporarily waived the Vermont statute regarding informed consent and telehealth during the state of emergency. To the extent permitted under federal law, this waives:
. . . obtaining and documenting a patient’s oral or written informed consent for the use of telemedicine or store-and-forward technology prior to delivering services to the patient in accordance with 18 V.S.A. § 9361(c), if obtaining or documenting such consent, or both, is not practicable under the circumstances.
All practices are encouraged to ensure patients understand, and are comfortable with, the remote delivery of health care services.
Normally practices are required to inform patients about their use of HIPAA-compliant platforms. The federal government and state have dropped enforcement of HIPAA-compliant platforms for delivering telemedicine during the PHE. Commercial payers do not manage these investigations, and therefore the state and federal changes also remove any requirements written in their guidance (see the explanation from BCBSVT here). HHS guidance encourages providers to discuss the implications of this change, but does not require it.
“Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.” (HHS, Posted 3/23/20)
Payers usually require a practice to ensure that patients understand a telemedicine visit, including one delivered over the telephone, is the equivalent of the in-person service and is a billable service. This information may be delivered in the appointment itself or at the time of setting up the appointment, and should be recorded in the patient’s record. Check individual plans for details.
VT Medicaid and commercial insurance do not have a cost share for brief telecommunications services (for example, triage calls), and therefore the rule about agreeing to be billed usually comes up in the telemedicine guidance for services that are equivalent to in-person visits. However, Medicare does have a cost share for those brief telecommunications services and they do have an expectation that patients will consent prior to receiving the services.
Medicare includes copays for “brief telecommunications” codes, and these come in two types - “Virtual Check-Ins” and “e-Visit” (patient portal communications). These services need to be initiated by the patient, although a provider can educate patients about the availability of the service. During COVID-19, CMS accepts annual consent to services and for this consent to be obtained prior to the services or at the time of service (eg the start of an appointment).
An additional Medicare complicated during COVID-19: During COVID-19, Medicare has also added brief telephone calls to their list of accepted “telehealth” services (note, as described previously, Medicare uses telehealth where we say telemedicine). This change means that codes not considered to be an office visit replacement in Vermont state rules are treated that way by Medicare. We know this is incredibly confusing and really, truly apologize for that. You will need to discuss cost share implications of brief telephone services with Medicare patients. Remember also that federal rules allow for waiving telehealth co-pays during the pandemic, should the cost prove to be an impediment to care. The health care practice will then absorb that cost.
One final note regarding patient consent to disclose medical files under 42 C.F.R. part 2, SAMSHA has provided this guidance on emergency medical exemptions as relates to disclosures to medical personnel treating substance use disorder during COVID-19.
[page last updated 7.2.2020]
Platforms & Technology
An early change in COVID-19 response quickly expanded the number of platforms that could be used for telemedicine. Guidance from the Office of Civil Rights indicated OCR would not be prosecuting use of non-HIPAA compliant devices to deliver health service during the COVID-19 emergency. This does not mean anything goes, public-facing communications platforms are not allowed (think Facebook Live). Additional implementation guidance is available from the Department of Health & Human Services, along with this FAQ. Note that there is almost no possibility that the flexibility around HIPAA will continue after the Public Health Emergency.
The Vermont Legislature has similarly waived HIPAA compliance during the COVID-19 emergency and also removed that clause from patient consent rules (see previous section on patient consent).
For further context on current rule suspension, the Feldesman Tucker Leifer and Feidell Law Firm provides this April 8 post on patient confidentiality during COVID-19.
Much of the current discussion around “HIPAA-compliant platforms” addresses video conferencing platforms used for telemedicine. Previous guidance describes other remote communications:
- U.S. Dept. of Health and Human Services rules regarding HIPAA and email. (Note this is emails to a patient, not emails between business entities)
- FCC clarification regarding the use of the telephone, and an article explaining the clarification.
- Texting is permitted in the current temporary COVID rules as a non-public-facing communications platform. Beyond that there is some suggestion that OCR views texting as comparable to emailing, and a 2017 CMS hard line against texting was later walked back. Rules exiting the public health emergency may shed more light.
It’s important to note that using a “HIPAA-compliant” platform does not in itself resolve confidentiality concerns. Entering into a Business Associates Agreement with, for example, Zoom means that you have a legal agreement around use of the data in the system and liability assigned should anything go wrong. A whole range of factors from patient unfamiliarity with how to use the technology to failure to implement appropriate clinical protocols can create privacy concerns. A HIPAA-compliant platform vendor will do a risk assessment and plan to address the risk, but this is not just a platform selection issue.
When in doubt, consult a lawyer. And a risk compliance officer. At the very least, review this webinar on legal considerations for HIPAA and patient privacy hosted by the National Consortium of Telehealth Resource Centers (11/18/20).
Additional information is provided in this packet on Patient Confidentiality prepared by the National Association of Community Health Centers, 9/14/2020.
Commonly Used Audio-Video Platforms
There is a network of federally-funded telehealth resource centers across the U.S., and the one focused on technology is the National Telehealth Technology Assessment Resource Center (or TTAC). Their resources include a series of technology toolkits. For detailed discussion of platforms, we recommend starting there. Additionally, the Center for Care Innovations hosted a series early in the pandemic with Telehealth 101 technology discussions, linked here.
From HHS Guidance on HIPAA Compliance, March 19, the list below includes some vendors that represent that they provide HIPAA-compliant video communication products and that they will enter into a HIPAA BAA.
- Skype for Business / Microsoft Teams
- Zoom for Healthcare
- Doxy.me (which is not the same as Doximity, another option)
- Google G Suite Hangouts Meet
In Vermont, surveys at the start of COVID-19 showed that of these platforms Zoom was by far the most frequently used (75% of practices have used it), significantly outperforming the next most-common HIPAA-compliant option (Doxy.me at 25%).
Examples of platforms that are not HIPAA-compliant, but that are acceptable during the COVID-19 emergency:
- Apple FaceTime
- Facebook Messenger video chat
- Google Hangouts video
- Skype (not the business version)
- Zoom (not the Healthcare version)
In Vermont practices, the non-HIPAA version of Zoom and Facetime are the most popular options.
A list of vendors with notes on each from the Adirondack Health Institute
This fact sheet from the National Organization of State Offices of Rural Health pre-dates COVID-19, but has some simple platforms listed and solid advice.
Vendors Offering Free or Reduced Cost Platforms for patient-provider communications during COVID-19: This slide deck from the Northeast Telehealth Resource Center (5/20) includes a variety of free and reduced price telehealth options during COVID-19. They were compiled largely from the Mid-Atlantic TRC, which also offers this “selecting a vendor” toolkit.
Key Questions You Will Want to Answer When Exploring Telehealth Platforms From a longer toolkit posted by the AAFP, which is gathering answers to these questions across vendors:
- Can I exit my contract at any time (i.e., not locked into a 2-year contract)?
- Is there a waiting room feature so I can queue my patients up?
- Is the platform device agnostic (i.e., can physicians/providers and patients use device of their choosing for virtual care)?
- Is there an out-of-office message noting we’re not available to take your call right now? (i.e., during off hours or overnight)?
- Does the software has the ability to schedule a visit? Note: This is a more advanced feature; it’s not absolutely required to have now, but it’s very nice to have
- Is the platform deployable in days?
Note also that a health care practice does assume some legal responsibility to talk with a vendor and confirm their claims that they offer a HIPAA-compliant solution.
A related topic area to platforms is broadband capacity - or lack thereof for patients and providers working from home. This is actually a system of inter-related issues, some of which have short term solutions under COVID-19. There’s broadband infrastructure, the question of what services are available at what speeds (if you’re running a tele-ICU that’s not the same as emailing a photo of a rash), patients’ ability to afford adequate speeds, and equipment. Here are some resources on this topic:
Broadband for Telehealth in Vermont - a short podcast interview with the Public Service Department (5/14)
Federal Funding Sources to Support Patient Connectivity (5/6) - a list of programs compiled by the VT Legislative Council.
The Department of Public Service Division for Telecommunications and Connectivity resources including:
- Connectivity Resources During COVID-19
- Map of Public WiFi Hot Spots
- Broadband Availability Maps
- Map of Broadband at VT Health Care Practices
- Tips for Telehealth Connections
The Vermont legislature also devoted a portion of the state’s CARES funding to closing the broadband infrastructure gap for the purposes of telehealth and accessing remote education. This funding timeline was tight due to federal restrictions and also required a high level of specificity in the addresses served - someone needed to be experiencing current difficulty accessing health care, we couldn’t just go with the logic that everyone needs telehealth access because it’s an essential service.
- Interactive Broadband Map & Survey of Locations Needing Service
- PSD Update to the Legislature on CARES-funded Deployment Plans - 8.28.20
- COVID Response Telecommunications Recovery Plan - 12.20.20
Vermont has been working on closing the digital divide for many years now. The Vermont Council on Rural Development managed two such programs, eVermont (2010-2012) and the Digital Economy Project (2012-2013). Both generated a lot of resources on the many different strategies for closing digital gaps in our communities. . . sure, it’s a little nostalgic to look at a broadband toolkit circa 2012, but less has changed than you might think.
See also the Digital Divide section of this toolkit.
[page last updated 1.04.2021]
Implementation Toolkits - General
These are all toolkits that have been either created in response to COVID-19 or significantly updated to reflect this response.
National Consortium of Telehealth Resource Centers - COVID-19 Telehealth Toolkit (published March 19) - See the regional TRC toolkits below for more detailed options, this early toolkit is notable for including articles and case studies on effective telehealth use in other epidemic situations.
Northeast Telehealth Resource Center - COVID-19 telehealth response toolkit find it here. Includes links to other regional telehealth resource center toolkits:
- MATRC Toolkit
- Remote Patient Monitoring Toolkit
- NRTRC Quick Start Guide
- NCTRC Toolkit
- GPTRAC Quick Start Guide
With CRF funds, NETRC has also been developing trainings and toolkits to support telehealth implementation leaving the emergency:
American Medical Association - Telehealth Implementation Playbook
American Academy of Pediatrics - Telehealth Resources for Pediatricians
American Academy of Family Physicians - Telehealth Guide for Family Physicians
National Association of Community Health Centers - Telehealth Implementation Quick Guide
U.S Health & Human Services - Telehealth Resources for Patients & Provider and Virtual Case Management Considerations & Resources
American Psychiatric Association - Telepsychiatry toolkit
American Academy of Child & Adolescent Psychiatry - Telepsychiatry toolkit
- Teledentistry in COVID-19 Webinar (4/6)
- “Fast Track to Teledentistry” White Paper
- Patient Perspectives on Teledentistry (6/30)
- Mouthwatch - Adapting Teledentistry for COVID-19 with Dr. Paul Glassman
NETRC Introduction to Teledentistry (pre-dates COVID-19, but useful)
Additional Training Resources for Implementation
The resources above are focused on quick roll out of telehealth tools, some options for additional training:
- Telehealth Coordinator Online Training (California Telehealth Resource Center)
- Clinical Telehealth Guidelines, Standards, Policies (Resource List Compiled by NETRC)
- Clinical Telehealth Training Webliography (Resource List Compiled by NETRC)
- Notes on Clinical Research for Telehealth (from 7/20 NETRC presentation)
- NYS Telehealth Training Portal (opened in January 2021, we are hoping for / anticipating similar portals to be developed for other states. . . states like Vermont).
[page last updated 1.13.2021]
Workflows & Focused Toolkits
A few things that should happen as part of developing your patient workflows, which not every example here includes so we’re saying it at the top:
- You need to know where your patient is physically located and who to contact to reach them in an emergency.
- If this is a billable visit, your patient needs to understand the billing and agree to be billed.
- Please review the earlier section regarding patient informed consent for telehealth services. It is waived during the public health emergency but it is still best practice.
- While audio-only services are allowed during COVID-19, audio-visual is preferred and it’s recommended to have a system for determining (and recording) if patients can receive audio-visual services. See the Digital Divide section for more.
MidAtlantic Telehealth Resource Center (MATRC) - “Thinking About Workflow” Toolkit includes many links to sample workflows (go to Best Practices for Conducting a Telehealth Visit > Workflow Considerations). The most basic:
UVM MC Video Visit Workflow - this is a basic workflow (pre-COVID-19) used as a starting point for discussion on a 6/4 Telehealth Office Hours conversation about workflow design, see additional resources and the recording that goes with it here.
Rutland Community Health sample Telemedicine Workflow using Medent platform.
Center for Care Innovations - FQHC Telephone Workflows & Guidelines
National Consortium of Telehealth Resource Centers Webinar - Mapping and Designing Telehealth Clinic Workflows
Workflows and Documentation Webinar presented by HHS and NCTRC, scroll down to find handouts and video (8/5/20)
Health Information Technology Evaluation and Quality Center (HITEQ) - Workflow Guides for Telehealth
AMA Telehealth Playbook - Workflow is pp 48-57, with a year’s supply of sports metaphors.
American Academy of Pediatrics - Virtual workflow considerations.
Considerations for Setting Up Telemedicine with Suicidal Clients During COVID-19 - Center for Practice Innovations.
Conducting a Physical Exam Remotely:
- Clinical Best Practice and the Art of the Tele-Physical Exam from the HHS Telemedicine Hack series (webinar + resource slides).
- Video Series Demonstrating a Remote Physical Exam - from Mid-Atlantic Telehealth Resource Center (scroll down through the toolkit).
- Providers Course in an Effective Telehealth Physical Exam - from Thomas Jefferson University, costs $100 but does come with continuing education credits.
- MATRC telehealth toolkit for MAT implementation.
- Policy report on FQHCs providing remote SUD services, includes case studies.
- Drug Enforcement Administration guidance on implementing MAT services during COVID-19.
- Substance Abuse and Mental Health Services Administration (SAMHSA) guidance on Opioid Treatment Programs, including remote tools, during COVID-19 (scroll down to OTP section).
Managing Chronic Conditions:
If there is a “classic” example of using telehealth, predating COVID-19, it is managing chronic conditions. Well, maybe tele-radiology. But chronic conditions are a close second. And it makes sense, telehealth lends itself well to anything that is improved by regular check-ins with a clinician, possibly combined with review of data that can be collected at home using simple devices (for example blood glucose levels, weight, or blood pressure readings). In the private business world, we’ve seen telehealth businesses jumping into this field, for example with Teledoc’s acquisition of Livongo, a telehealth company specializing in diabetes management.
Medicare has its own Chronic Care Management program (explained in this online booklet). In this case we’re talking both about Medicare’s CCM and generally about managing chronic conditions with remote tools. These services often fall into the telehealth categories of Remote Patient Monitoring and mHealth.
The fact that managing chronic conditions often shows up in telehealth resources that pre-date COVID-19 and may be found covered under different types of telehealth tools can make this topic confusing to research. Here are some starting places:
- Because this type of care can use different telehealth modalities, it's not a bad idea to review what those are, for example in this overview from the Center for Connected Health Policy.
- CMS provides a toolkit for implementing CCM - the program debuted in 2015, and these resources have been regularly updated since then.
- FQHCs, Telehealth and Chronic Care Management - NCTRC Webinar (5/1/19)
- FQHCs / RHCs and the CCM Program - HITEQ presentation and resources (9/10/16)
- NETRC presentation on clinical research, including a bibliography of research on telephone-based services (a lot of chronic condition management falls into this category). In the NETRC resource library you can also find RPM, mHealth (using apps to manage conditions) and do a keyword search on “chronic”.
- Remote Patient Monitoring 101 and Remote Patient Monitoring 201 - presentations & resources from the NETRC / MATRC telehealth conference, June 2020. See also the MATRC Remote Patient Monitoring toolkit.
- AMA Playbook for Remote Patient Monitoring
- AHRQ The Evidence Base for Telehealth (May, 2019) includes a review of studies focused on chronic condition management (2017)
- TTAC Technology Toolkits can help with understanding mHealth apps or at-home monitoring devices.
eConsults (this is a common form of store and forward telehealth):
Vermont Medicaid has posted their new policy on reimbursement for store-and-forward for interprofessional consultations, effective July 1. Commercial payers are also required to expand their store-and-forward options.
Sometimes called “eConsults”, this service allows primary care providers to submit clinical questions about a patient to a specialist and receive a treatment plan or recommendation for specialist referral back. These consults are used successfully to keep treatment in a primary care home (when appropriate), reduce unnecessary travel burdens for specialist visits, and reduce wait times for those patients who do require specialist treatment. As with managing chronic conditions (above) eConsults were an area of focus prior to COVID-19 and so resources span before and after the public health emergency.
Here’s some more information on this topic:
- eConsult Presentation - VPQHC Office Hours (8/5)
- Milbank Memorial Fund Report on eConsults (May, 2020)
- eConsult Toolkit & Work Group (includes COVID-19 tools)
- Using Remote Interprofessional Consults in Vermont (podcast episode)
- Testimony on H. 723 (the bill that led to reimbursing eConsults across professions in Vermont)
Some programs incorporate a form of eConsult into a larger mentoring and training mission, which adds a component of addressing workforce gaps. Two well known examples:
- The MAVEN Project - see also their article in NEJM about their program's role in COVID-19 response.
- Project ECHO at the University of New Mexico - see also this profile from the Robert Wood Johnson Foundation.
Clinical Research - General Sources
If it’s actual clinical telehealth research you want, there’s that as well, although much of it falls into a “pre-COVID” bucket.
The Northeast Telehealth Resource Center maintains a searchable library of thousands of telehealth resources that can be filtered by type, including journal articles. You can also refer to these NETRC compiled references:
Preparing for Visits:
With the changing rules around telehealth use for COVID-19, many previous outreach materials for patients are out of date, giving incorrect specifications around acceptable devices and platforms. Here we’re collecting new options designed for COVID-19 times.
Helping a Patient / Client Understand Telehealth - MATRC Toolkit
Telehealth Access Toolkit from VPQHC Connectivity Care Packages Program (helpfully, it opens with how to clean and disinfect electronics)
- What to Expect from a Telehealth Visit (short video) from Pacific Basin Telehealth Resource Center & Hawaii Department of Health
- Nice example of a webpage explaining telehealth from Penobscot Community Health Care in Maine.
- Sample Pre-Visit Email from UVM Health Network - includes Zoom instructions
Patient Guides to Common Telehealth Platforms - University of Arkansas
Patient Guides to Accessing Telehealth Platforms - Telehealth Access for Seniors
- Patient Instructions for a Telehealth Visit (for a visit using a video camera) from CaravanHealth
- Patient Instructions for a Telehealth Visit from Humana
- Tips on Maximizing Broadband for Telehealth Visits from VT Department of Public Service
- The U.S. Department of Health and Human Services telehealth resource page - also available in Spanish.
- Tips to Keep Your Telehealth Visit Private - SAMHSA
- How To Prepare for a Video Visit with Your Mental Health Provider - SMI Advisers
- Patient explanation of Teletriage from Greater Buffalo AOC
During the Visit - Accessibility Issues:
Some resources for ADA-compliant and accessible sites, translation, interpretation, and systems to help patients who are hard of hearing.
- W3C Web Accessibility Initiative offers a range of resources to make websites accessible and usable for everyone.
- ADA Toolkit - Websites, circa 2010. Ironically, the ADA.gov website displays several things that are not considered access-friendly (non-obvious links that are difficult to hover over, text in very very disparate sizes). Much like HIPAA compliance isn’t the state of the art in online data privacy protection, ADA compliance isn’t state of the art for website accessibility - these are fairly old legal frameworks, not telehealth thought leadership.
- Because we support people who spend a lot of time writing about technical issues that only they and a few other random folks care about, there’s also this channel of posts on Medium.
The Department of Health and Human Services and National Consortium of Telehealth Resource Centers hosted a session on technology and accessibility on 10/26/20 as part of their telehealth hack series:
- Video Recording (does not include DOJ presentation on ADA compliance).
Vermont Telehealth Office Hours on overcoming language and communications barriers:
- Telehealth with Individuals who are Hard of Hearing or Deaf with Rocky Kelly (UVM HN) (6/24)
- Telehealth and Translation Services with Dr. Heather Stein (CHCB) and Kristy O’Neil (Brattleboro Memorial Hospital) (7/9)
Additional resources referenced in the above webinars:
- Hearing Loss Association of America - Communication Access Plan (CAP) This is a tool that could be utilized by deaf and hard of hearing individuals and emailed to the provider prior to the telehealth visit.
- HITEQ toolkit on telehealth for patients with limited English proficiency during COVID-19 response.
- How to Bring a Stratus Interpreter into a Zoom Meeting This resource was shared by UVMMC. Stratus Video is a language services company.
- Video Remote Interpreting (VRI) Platforms:
Partners Interpreting: https://www.partnersinterpreting.com/
Linguabee VRI: https://www.linguabee.com/interpreting-services/video-remote-interpreting-vri
- UVMMC Language Access Services (Interpreting & Translation) website
- COVID-19 Translations: Vermont Department of Health
- The Vermont Multilingual Coronavirus Communication Task Force has posted Coronavirus resources on YouTube for Vermonters in Multiple Languages.
- The Association of Africans Living in Vermont (AALV) provides interpreter & translation services; these professionals are available to participate in telehealth visits.
- UCSF Center for Vulnerable Populations offers resources for safety net providers implementing telehealth with patients who have limited English proficiency, including COVID-19 information in 35 languages.
Guides for Providers Communicating with Patients:
There are also many resources out there for setting up a good telehealth experience for patients, from sound to lighting to remembering to look at the camera:
- This tele-etiquette series from South Central Telehealth Resource Center has a lot of good material on engaging with patients via telemedicine.
- Telehealth etiquette in a checklist format from the Heartland Telehealth Resource Center.
- Great Plains Telehealth Resource Center has posted this presentation from a workshop on telehealth etiquette.
- The Center for Care Innovations offers this recording of a recent (5/7) webinar on patient presentation, including practical considerations for effective video visits from home.
- “Webside Manner” journal article
- Center for Care Innovations "Considerations for Reaching and Engaging Diverse Patients"
Patient Communications After the Visit:
These toolkits address engaging patients in telehealth design / telehealth evaluation:
- Patient Satisfaction Survey Toolkit - Center for Care Innovations
- Engaging Patients in Co-Design of Telehealth - VPQHC Office Hours Presentation (scroll to June 17, 2020)
- Patient Engagement & Telehealth - UVM Health Network case study - VPQHC Office Hours Presentation (October 7, 2020)
- Press Ganey studies patient satisfaction with telemedicine, and in May released this study about the early days of COVID-19 induced remote care. They also have a resource page with information on patient engagement during COVID-19.
[page last updated 11.4.2020]
There has been a lot of media coverage of the digital divide as part of pandemic response and telehealth access. It isn’t feasible to cover it all here, but some articles to give the flavor of what’s being discussed:
- Patient Characteristics Associated with Telemedicine Access - JAMA, 12/29/20
- Technology Divide Between Senior “Haves” and “Have-Nots” Roils Pandemic Response - Kaiser Health News, 7/24/20
- What Will It Take to Achieve True Equity in Telehealth? - HealthTech, 9/9/20
- JAMA Study: 38-percent of Older U.S. Adults Ill-Equipped for Video Visits - Healthcare Innovation, 8/7/20
- Digital Health Equity Framework - Journal of Medical Internet Research, 6/2/20
- The Expansion of Telehealth - Equity Considerations, IMPAQ Health and American Institutes for Research, 9/20
A few good general sources of information on digital divide as a context for telehealth include the National Digital Inclusion Alliance, NCTA (Internet and Television Association), Rural Health Information Hub, Pew Research Center.
The HITEQC Center offers this toolkit for FQHCs (October, 2020). In the UK, the Widening Digital Inclusion program at the National Health Service published a report in November, 2020, based on a 2017-2020 study on addressing digital inclusion as a social determinant of health. The study received funding from the Good Things Foundation, which focuses their charitable giving on digital inclusion issues.
Broadband Infrastructure and Affordability:
Links to resources on this topic are found in the Platforms and Technology section. A good starting point in general is the Vermont Public Service Department and the connectivity section of their website for up to date information on both progress towards making broadband available across Vermont and programs to help reduce the cost of access. Their site includes COVID-19 response initiatives. You can also hear the PSD explaining broadband infrastructure in Vermont in this episode of the Policy in Plainer English podcast.
At a national level the goal of getting everyone connected for telehealth is the domain of three entities: the Federal Communications Commission (FCC), the Department of Health and Human Services (HHS), and the U.S. Department of Agriculture (USDA). Why USDA? Because they are in charge of rural utilities. These three entities signed a Memorandum of Understanding to work together to promote rural telehealth at the end of August, 2020. This was at a time when there was a flurry of activity on telehealth, this article summarizes the context for the MOU. We have also prepared a short cheat sheet on the primary federal programs supporting broadband access and expansion, including programs focused on health care.
On the topic of utilities and telehealth access, it’s important to remember that many people get online via smart phones. For lower income patients, that is a more common route to access than home-based Internet + computer. Nationally, 26% percent of low-income households are entirely dependent on their phones for access (according to Pew research) and some studies during COVID-19 show that smartphone is the most common device to access telehealth (see patient and provider studies linked later in this section).
At the beginning of the COVID-19 emergency, the federal government recognized the critical role that smart phones provide in access and waived a previous requirement that prevented telehealth from being accessed by phone. Yes, that seems like a weird thing to need to do in 2020, recognize that phones can access the Internet. It’s important to remember that the federal framework for telehealth, and in particular Medicare coverage of telehealth, is rooted in an earlier technological age - there’s an assumption that you will need to access it through a fancy video set up at a clinic. Times have changed.
The federal waiver for telehealth via smart phone did not necessarily allow telehealth to happen without the video component (although one might reasonably ask, how would the government know if you turned on your video screen?). Separate rules allowing audio-only telehealth - including via landline - came early at the state level and later at the federal level. Details are in the Reimbursement section of this guide. In Vermont these rules are temporary to the public health emergency, although other states have made them permanent.
Flexibility in devices, as mentioned above, is one way to help with equipment access challenges. Outside of pandemic times, there is a lot of focus on how to address both equipment and infrastructure issues by opening up public access points such as libraries. Obviously, in the world of health care, that gets a bit trickier because of privacy concerns (do you really want to show that rash to a camera in the middle of the library? No, and the librarian doesn’t want you to either). But there are options. For example, there may be Internet access spaces built into affordable housing or residential living for seniors.
With CARES Act Funding from the Vermont Legislature, VPQHC is currently running a Connectivity Care Packages pilot program to connect patients with equipment and support for accessing telehealth. A Policy in Plainer English episode provides background on the initiative. On November 4th, the VPQHC Office Hours featured a report on the early roll out of the Connectivity Care Packages. There are also non-profit organizations that provide devices, such as the Telehealth Access for Seniors program that VPQHC worked with as part of developing the Connectivity Care Packages.
Federal sources of funding for devices are less robustly developed than the sources of funding for making the Internet connection. Traditionally there has been hesitation to fund devices due to concern about restricting their use to health care. Patients might use a tablet to search for work, connect with their family, find information on consumer protections, register to vote, seek assistance with food and housing, check a public transportation schedule, build digital literacy skills, access education. . . you get the picture. That being said during COVID-19 the FCC opened a $200 million fund that could be used to support equipment purchases. It ran out of money long before it met all the needs, and at the time of this writing calls continue for improving on the program and reopening the opportunity.
Digital Comfort / Digital Literacy
First, a word on digital comfort / digital literacy. We often think of this as the patient or provider knowing how to use the technology tools . . . but just as often it’s the technology that’s the problem, not the patient. This ranges from making systems accessible to patients who may be hard of hearing, have visual impairments, motor skill impairments (even carpal tunnel makes some sites literally painful to navigate) and who have limited English proficiency, all the way through to designing systems that are straightforward for the average non-computer-tech person to navigate.
So let’s not pretend digital comfort / literacy lies only with teaching people how to use technology. It’s a close cousin to accessibility (see our Patient-Facing Materials section for more on this topic, W3C Web Accessibility Initiative is a good starting point).
This all being said, teaching digital literacy is an important part of the puzzle and here are some resources:
- Telehealth & Digital Divide - OneCare Noontime Knowledge, 8/10/20. This is an annotated copy of the slide deck, it and builds a framework for thinking about some of these issues.
- The VPQHC Connectivity Care packages referenced previously also come with technical support assistance for patients, provided by Telehealth Access for Seniors, which has written guides on their site. Another Vermont-based program that addresses digital skills is Technology for Tomorrow.
- Not quite in Vermont but nearby is Tech Goes Home out of Boston, which addresses digital equity across a broad range of opportunities not just health care access.
- Two commonly-referenced self-guided online modules for learning digital skills are Northstar Digital Literacy and GCF Learn Free, and GCF Learn Free in Spanish.
- Public libraries have been at the forefront of digital literacy work pretty much since the computer was invented. The American Library Association / Public Library Association offers the Digital Literacy Initiative collection of tools for helping patrons navigate online and improve digital literacy.
Patient Engagement as Part of Bridging the Digital Divide:
Perhaps the best way to know way to know what patients require to help them engage with telehealth is to ask. The Patient-Facing Communications section of this resource guide includes some examples of patient engagement studies. Below we’ll look at the type of insights these studies can provide.
In November, 2020, Connecticut released the first detailed statewide study of patient use of telehealth during the ‘second phase’ of COVID-19 (ie not the chaotic March-April time period when use went off the charts, but Sept-Oct of 2020). It shows some of the actionable insights that patient studies can reveal. For example:
- Health care providers are a critical source of information about the availability and appropriateness of telehealth. In other words, we can’t assume that patients will ‘just ask’ if they need or want a remote option - practices need to be proactive in talking through options with patients. This will be particularly true if talking through different barriers to care (transportation, child care, Internet access, etc.).
- A smartphone was the most common way for patients to connect to telehealth.
- Almost three-quarters of patients liked not having to travel to a provider’s office, and 45% like not having to wait in a waiting room for the appointment to start - but interestingly these benefits were not tied to COVID-19, only 2.3% reported liking telehealth because it’s a safe option during COVID-19. This indicates that patient interest in telehealth will continue after the pandemic. And in fact 82% said they would use telehealth again, and one-third preferred it over in-person appointments.
- Among patients who do not prefer telehealth, the top change that would increase their interest is to have access to a quiet / private place for the appointment, 32.5%. This was more that the 26% who reported access to technology as being a barrier.
- Patients using telehealth as part of mental health services are significantly more interested in ongoing access than patients using it for other medical appointments.
- Two-thirds of patients were interested in some form of monitoring device - for example a FitBit, blood pressure cuff, etc. This interest correlates well with AHRQ / HHS findings that remote patient monitoring as part of managing chronic conditions is one of the highest impact applications for telehealth. However, it's one of the formats least likely to have been implemented in COVID-19 response, which focused more on replacing traditional office visits and triaging urgent care.
There’s more to the Connecticut study, but you get the idea. Another set of broad patient data is the November 13 study from California focused on low income patients and safety net providers. There are also some private sector “consumer market” studies that come out regularly, although these may not focus on patients who experience barriers to digital care. Examples are the J.D. Power telehealth satisfaction studies, Accenture Health Care, and the Amwell annual report on telehealth adoption. The COVID-19 health care coalition is also doing survey work on telehealth, as of this writing the physician survey had been released but the patient survey was still in process.
For an excellent pre-COVID example, there’s Christina Quinlan’s discussions of how she used telehealth at an FQHC on an Island in Maine to meet patient needs prior to COVID-19, then adjusted during the emergency. There is presentation on using telehealth to address Social Determinants of Health (the website will / should prompt a free registration to access), another similar presentation on an NCTRC webinar, and it even gets a shout out in this Policy in Plainer English podcast on screening for food insecurity.
Engaging patients in how they’re using telehealth right now can help both bridge divides during the pandemic and set the stage for future work.
[page last updated 1.04.21]
Case Studies - Formal & Informal
Telehealth & COVID-19 Podcast Series
The Policy in Plainer English podcast interviewed FQHCs around Vermont on the use of telehealth in their initial response to COVID-19. It’s more vignette than “case study” but. . . close enough. The special series included 10 episodes:
- Telehealth Special Series - Intro
- Telemedicine vs. Telehealth
- Telehealth Reimbursement & COVID-19 (note that specific rules change frequently, and for the most up to date version check this update page).
- Telehealth and the Telephone
- Telehealth and the Telephone - Chronic Care Management (not everything fit in the first episode)
- Broadband for Telehealth
- Telehealth Reimbursement & COVID-19 Part Two (same caveat as above, check our update page if you want specific guidance)
- Telehealth and Provider Consultations
- Telehealth and Global Budgets (can’t get enough of this topic? We recommend Season One: Welcome to Payment Reform)
- Transportation and Telehealth
- Final Episode
Other Case Studies:
Balancing Virtual and In-Person Care - Brigham Health for Harvard Business Review, Nov 2020
Results of Patient Surveys for Connecticut FQHCs - Surveys administered Sept-Oct 2020
Memorial Hermann Maps Out a Strategy for Primary Care Telehealth -Oct 20, 2020 Profile
Case Studies presented in the national Telemedicine ECHO program - July 22 - Sept 23
Presentations from 2020 NETRC / MATRC Telehealth Virtual Conference - if you didn’t register, you can sign up here to gain free access to the recordings and materials.
Rand Corp Study of 9 Safety-Net Providers - telehealth pre-COVID - July 29
Bassett Healthcare Network - comprehensive telehealth response to COVID-19 - June 26 (presentation)
Long Island Select Health Care - creating a sustainable chronic care management approach during COVID-19 - June 19 (presentation)
Colorado Health Institute - Telemedicine policy report containing four COVID-response case studies, May 11
Patients Discuss Telehealth - AARP, April 17
Rapid Deployment of Telehealth During COVID-19 in Rural MN - RHI Hub, April
Rapid Tech Deployment to Reach Vulnerable Residents in Washington State - Milbank Memorial Fund, April 2
Montreal Family Doctors Turn to Telemedicine - Montreal Gazette, March 24
Dartmouth-Hitchcock Use of Telemedicine in COVID-19 - Concord Monitor, March 21
Opportunities to Expand Telehealth Amid Coronavirus - Health Affairs, March 16
Telehealth During COVID-19 - American Journal of Managed Care, March 13
Telephone Urgent Care Visits for Primary Care - Center for Care Innovations (2014 case study republished in their COVID-19 materials)
Planning for the Future
What We Can Learn About the Future:
“Data-driven” and “evidence-based” health care is a good thing. Data driven by a pandemic is. . . problematic. First, there’s the trouble gathering it. Second, pandemic response telehealth is its own beast - not only did you not have a chance to be thoughtful about implementing (remember telehealth visits went from near-zero to 90% of visits overnight for some practices) but the people using it are different (normally the people using telehealth are enthusiastic early adopters not people pushed there by a pandemic) and the types of applications are different (a lot of office visit replacements).
However, we must soldier on, undaunted by imperfect information.
The first thing to remember is that “telehealth” is a field that has been studied for decades. Literally, since before some of today’s telehealth experts were born. It did not begin with COVID-19. A great starting point is the Northeast Telehealth Resource Center’s library of research and this slide deck from their 7/22 presentation on finding good research. NETRC is very fond of Webliographies as well.
We also have access to increasing amounts of data from within the COVID-19 public health emergency:
In Vermont, in Spring 2020, both the Vermont Medical Society and OneCare Vermont polled practices on telehealth use. They presented the results as part of the telehealth office hours series (June 11 & 18 - see also slide decks linked from those recordings).
In July, the Department of Health and Human Services gave us their first snapshot of CMS-collected data on telehealth utilization during COVID-19.
The COVID-19 Health Care Coalition is tracking real time data, including in telehealth.
The Patient-Facing Communications and Digital Divide sections of this resource guide also provide examples of systems being used to measure patient engagement with, and opinions about, telehealth during COVID-19.
Wherever there’s uncertainty combined with even the merest hit of data, you can be sure that thought leaders and experts will jump in with their opinions of ‘what’s next’. That is certainly true for telehealth. Some examples of these reports:
The National Taskforce on Telehealth Policy analyzed data available from the start of COVID-19, combined with individual stakeholder input, to outline recommendations for policy coming out of the pandemic in their September 2020 Report.
- The Bi-Partisan Policy Center published a report on 'Confronting Rural America's Health Care Crisis' in April, 2020, followed up by a telehealth infographic in July 2020, followed by a telehealth panel in November 2020. They're leaving nothing to doubt about whether they believe telehealth is a relevant tool for rural health care moving into the future.
- The Center for Connected Medicine brought in Sen. Bill Frist to moderate a roundtable of top telehealth executives to discuss the future in October, 2020, and produced a report on the results.
- Health care think tanks have quickly burnished their archive of telehealth analysis, including Milbank Memorial Fund, Commonwealth Fund, Brookings Institute, and the Rand Institute.
Another way to track where telehealth may be headed is to keep an eye on legislative initiatives.
- The Center for Connected Health Policy provides information on policy changes in telehealth, including at the state level, and regularly publishes analysis of policy responses. This work hasn’t slowed down in the pandemic. See for example their state legislative tracker tool.
- National associations publish their own agendas as well. Some examples (among many): the American Medical Association adopted a new telehealth policy in November 2020, the American Hospital Association advocates for telehealth policy at federal and state levels, the National Association for Community Health Centers is finalizing updated advocacy for recognizing community health centers as telemedicine providers (they are, obviously, in favor of that), and the Connected Health Initiative is an industry group advocating for consensus policy positions.
There are many groups and individuals thinking through the future of telehealth. On December 1st, 2020, the VT Department of Financial Regulation shared its working group report on the future of reimbursement for audio-only telehealth in Vermont. In that report VPQHC and the Statewide Telehealth Working Group included a short report on the best available information on the quality of audio-only telehealth. In February, 2021, the providers coalition compiled an addendum that included some more recent studies related to audio-only. This is one example of how groups are moving to both work with the information we have now and set up the structure to collect better information for the future. New insights come out every day, and be sure to check the tweet list at the front of this Resource Guide for the latest news and also updates on what parts of the guide have been recently change to reflect new information.
[page last updated 2.20.2020]