Recent Site Updates:
- Updated Planning for the Future with an expanded section on early data, inspired partially by the Taskforce on Telehealth Policy report, 9/17.
- Updated Reimbursement Guidance with links to federal discussions (nothing finalized), 9/16.
- Updated Case Studies section with Rand Study on safety net providers and access link to NETRC / MATRC conference recordings.
- Updated Planning for the Future with a digital divide section.
- Updated Medicare section of Reimbursement Guidance to reflect new permanent changes, 8/4.
- Updated Patient-Facing Communications with more on resources to facilitate communication during the visit, 8/3.
- Added Telehealth Bootcamp - 30 minutes every morning for one work week for a structured introduction to key telehealth concepts.
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
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, outside of pandemic times that form of telehealth wasn’t even considered terribly interesting. Telehealth includes everything from using apps to monitor chronic conditions to 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. Please note that Medicare uses “telehealth” and “telemedicine” in reverse of what everyone else says. The reason why is buried somewhere in Area 51.
- Telemedicine is live, audio-visual, interactive consultations between provider and patient. Most states had rules in place allowing telemedicine pre-COVID-19. 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 to 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 of course there's also just "telephone-based services" and that would span both telemedicine and telehealth. Do you see why some people do not like rules that specify particular platforms / devices and prefer technology neutral regulations? Yeah.
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
- Telemedicine (synchronous, interactive audio-visual that replaces an office visit) is covered at parity to in-person visits. This includes for mental health and dental services.
- Vermont does not have restrictions on locations for provider and patient, this included recognizing the home as a patient location.
- 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:
- 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 had a published list of 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 them.
- Medicare has some audio-only options during COVID-19 this is done both by listing individual codes as having “audio-only” and reimbursing specific codes 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.
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. Currently the Department of Financial Regulation is leading a working group to recommend next steps audio-only reimbursement.
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 dental services to Vermont’s telemedicine parity rule.
- Adding interprofessional consultations for a range of professions (previously restricted to dermatology and ophthalmology).
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 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.
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)
- MedPAC initial recommendations on Medicare telehealth expansion, heavily favors advanced alternative payment models and downplays expansions that many had assumed would be continued, such as accessing telehealth from home and from non-rural locations (9/4/20)
- Summary of CMS Proposed Permanent Changes to Expand Telehealth - CMS Newsroom (8/3/20)
- Proposed changes to the Physician Fee Schedule for Calendar Year 2021, the Center for Connected Health Policy offers an explanatory video on implications for telehealth here.
- Proposed changes to payment and policy for Home Health Agencies for Calendar Year 2021
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).
[page last updated 9.16.2020]
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.
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. The Vermont Office of Professional Regulation has posted details here.
We also need it to go the other direction for Vermont-resident providers treating patients in their homes in bordering states. These rules are set by those other states. 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
- 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.
[page last updated 7.20.2020]
Patient Consent to Telehealth Services
During COVID-19, some of the rules around patient informed consent to receive telehealth services have changed. However, they haven’t changed if it’s practical to continue them and the 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)
- 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.
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 (aka triage calls), and therefore this rule usually comes up in the telemedicine guidance for services that are equivalent to in-person visits. It is especially important to be clear about billing for audio-only telemedicine.
Medicare includes copays for their “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).
One particular 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.
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 that 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. This is not just a platform selection issue.
When in doubt, consult a lawyer. And a risk compliance officer.
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
- Google G Suite Hangouts Meet
In Vermont, recent surveys show that of these platforms Zoom is 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
- 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?
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 to go with them, and also digital literacy / comfort. 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. We will update this section with resources as they become available.
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.
[page last updated 7.8.2020]
Sample Workflows & Implementation Toolkits
A few things that should happen as part of developing your patient workflows, which not every example here includes but which you should not ignore:
- 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 agree to be billed.
- Please review the earlier section regarding patient informed consent for telehealth services.
- While audio-only services are allowed during COVID-19, audio-visual is still preferred and it's recommended to have a system for determining (and recording) if patients can receive audio-visual services.
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.
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:
Center for Care Innovations - FQHC Telephone Workflows & Guidelines
Considerations for Setting Up Telemedicine with Suicidal Clients During COVID-19 - Center for Practice Innovations.
National Consortium of Telehealth Resource Centers Webinar - Mapping and Designing Telehealth Clinic Workflows
HITEQ - Workflow Guides for Telehealth
AMA Telehealth Playbook - Workflow is pp 48-57, with a surplus of sports metaphors.
American Academy of Pediatrics - Virtual workflow considerations.
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
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
- 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)
[page last updated 7.2.2020]
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
- What to Expect from a Telehealth Visit (short video) from Pacific Basin Telehealth Resource Center & Hawaii Department of Health
- 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
If preparing for a visit includes addressing digital literacy / digital comfort concerns:
- American Library Association / Public Library Association - Digital Literacy Initiative collection of tools for helping patrons navigate online and improve digital literacy.
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 I 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 (if you like this, you’ll love my series on dairy pricing systems).
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.
- 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 (AAVL) provides interpreter & translation services; these professionals are available to participate in telehealth visits.
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
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)
- Press Ganey studies patient satisfaction with telemedicine, and in May released this study about the early days of COVID-19 induced remote care.
[page last updated 8.3.2020]
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:
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)
Actual Clinical Research
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:
- Telehealth Resource Webliography for COVID-19 Pandemic
- Clinical Telehealth Guidelines, Standards, Policies
- Clinical Telehealth Training Webliography
- Best Practices in Telemental Health
- Critical Care Telehealth Webliography
- Resources for Emergency Telemedicine and Disaster Response
[page last updated 8.15.2020]
Planning for the Future
What Data Can Tell Us
“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 of our practices) but the people using it are different (normally the people using telehealth are the patients & clinicians who actively want to, not people who feel forced into it by a virus) and the types of applications are different (a lot of office visit replacements, much less of more sophisticated tools like eConsults or chronic care management).
However, we must soldier on, undaunted by imperfect information. Here are some places to start to piece together what data from the pandemic might teach us about telehealth:
- Before looking at 2020 data, don’t forget that “telehealth” is a field that has been studied for decades before now. 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.
- 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 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 Center for Connected Health Policy tracks 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.
- 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). Another OCV survey is planned for Fall 2020.
The other thing to remember is that “telehealth” encompasses a large range of tools to address an even larger range of needs. So the data we need may not be labeled ‘telehealth’ but, for example, a study of patient engagement and communications during COVID-19 response.
Press Ganey is one firm posting national patient experience studies during COVID-19 - these include telehealth-specific results plus general information that can both inform how to make a strong telehealth experience (patients that want staff to introduce themself and their role in real life want it even more in telehealth, for example) and also how telehealth can relieve patient concerns (diverting cases to telehealth when possible keeps waiting rooms less crowded, for example).
Similarly, individual practices may look at their own data to find gaps that emerged during COVID-19 that telehealth can help bridge. A good example of this is Christina Quinlan’s recent presentation on using telehealth to address Social Determinants of Health (the website will / should prompt a free registration to access). Provider associations and ACOs like OneCare Vermont can help with clinical data analysis. If you’re an FQHC in Vermont, talk to the Bi-State VRHA team for assistance if needed (we do more than just publish this resource guide).
Digital Divide Concerns
Tools and information for addressing the digital divide are featured in different parts of this guide. Some items to look at:
- Pew Research Center - Internet and Technology
- Presentation on Telehealth & Digital Divide - OneCare Noontime Knowledge, 8.10.2020. This is an annotated copy of the slide deck, it's pretty detailed (video will be linked when available)
- Public Service Department listing of connectivity assistance programs, including special programs during COVID-19. Listen also to this podcast episode on broadband & telehealth in VT.
- Telehealth Bootcamp discussion of platforms and platform considerations
- Tracking of both reimbursement policy and clinical education around audio-only telehealth - see Reimbursement Guide in this resource and Clinical Education note below
- See the Accessibility section of the Patient-Facing Communications chapter in this guide
- American Library Association / Public Library Association - Digital Literacy Initiative collection of tools for helping patrons navigate online and improve digital literacy
Clinical Education & Quality Improvement
Northeast Telehealth Resource Center presented (7/21) on research and clinical evidence for telehealth strategies, a recording is found on the VPQHC telehealth events site and the condensed notes are linked here. The short version is there’s a lot of research, much of it collected in NETRC’s resource library.
Of particular interest in Vermont is evidence to support continued, effective use of audio-only options for patients with health care access challenges. The Dept of Financial Regulation is considering this issue from a reimbursement perspective, VPQHC is reviewing resources for clinical education. Telephone-only services are the focus of the sample literature review in the NETRC presentation.
Expanding Tools - eConsults
While much of the COVID-time attention has been on the audio-visual telemedicine tools that replace an office visit directly, many of the more sustainable elements of telehealth focus on other options that blend in-person and remote consultations to deliver more effective care.
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.
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)
Alternative Payment Models and Telehealth
More information coming soon, in the meantime here is a podcast on why the future of telehealth may be intertwined with the future of alternative payment structures, in particular the progression towards global budgets.
[page last updated 9.17.2020]