- It can shift extra work to front-line medical providers
- Lack of a direct physical exam on patients
- Communication is through a platform rather than being face-to-face

Limitations to clinician-to-clinician communications

- devalued by insurance coverage 
- medical health providers cannot conduct a physical exam
- the patient's assessment is conducted solely on verbal cues


Limitations to telephone visits

- Technology requirements include the following: broadband internet/smart device, digital peripherals
- most complex conditions may be the least able to access medical attention


Limitations of video visits

- Requires staffing infrastructure
- There needs to be a method of integrating patient data into the electronic health record

Limitations of remote patient monitoring

- Commercial and Medicaid reimbursement is states’ decision
- 20% of states require payment parity between telemedicine and in-person services
- Medicare grants payment parity between telehealth and in-person clinical care. 
- Center for Medicare and Medicaid Services (CMS) issued waivers during pandemic.
- CMS and some local commercial payers have modified their payment policy during the COVID-19 pandemic.

Payment and reimbursement for telehealth services

- Telemedicine usage is limited within the scope of medical, nursing, and allied health field training
- Sudden integration of telemedicine say be seen as "disruptive" or "complex" by clinicians

Limitations to training clinicians in using telemedicine devices

States possess varying regulatory protocol and in regional healthcare systems that stretch across numerous states, interstate licensing can inhibit some physicians from providing remote care


Interstate/ intrastate regulatory protocol and telehealth

- Patient discomfort or privacy concerns in addressing sensitive topics
- Cultural disapproval of employing telehealth services in place of traditional in-person care visits
- Healthcare providers and patients with limited access to stable connectivity or technological devices needed for telehealth services

Social barriers to telehealth implementation

- States in the southern and midwestern regions of the U.S. had a lower percentage of hospitals with telemedicine intensive care units (Tele-ICU) 
- Lack of funding for teleservices in metropolitan areas/cities, where people are especially vulnerable due to high population density
- Although ~20% of the American population lives in a rural area, only 9% of physicians actively practice in rural areas 

Geographic region (in the U.S.) related telemedicine limitations

- Requires staff and a thorough infrastructure to optimize workflow

Limitations to patient initiated (tele-)communication

- limitations to clinician-to-clinician communications
- limitations of remote patient monitoring
- limitations of video visits
- limitations to telephone visits
- limitations to patient initiated communication
- limitations to training clinicians in using telemedicine devices
- geographic region (in the U.S.)
- payment and reimbursement
- Interstate/ intrastate regulatory protocol and telehealth
- social barriers to telehealth implementation

Syracuse University

Stanford University

University of Michigan - Ann Arbor

- Areas of care administered via telehealth
- Postpandemic recovery
- COVID-19 Related Telehealth Programs 
- Limitations of telehealth infrastructure
- Benefits to telehealth infrastructure
- Telehealth modalities
- Strategies to increase telehealth uptake
- Safeguarding telehealth services
- Opportunities of telehealth infrastructure
- Stay-at-home outpatient care
- Initial COVID-19 hospital surge
- Patient satisfaction
- Telehealth in surgery 
- Restructuring the Healthcare System using Telemedicine

Focuses of telehealth and telemedicine during the COVID-19 pandemic

Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic. (2020, June 10). 
https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html

Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic

With decreased emergency department visits due to the pandemic, the potential for increased complications due to the neglected complications is very high. This deficit can be characterized as "care debt" to the healthcare systems.
Developing a telehealth infrastructure can allow healthcare systems to manage and track complications with patients while maintaining data security and confidentiality.

Postpandemic recovery

- Emergency Telemedicine Consultation System
- Federal Communications Commission COVID-19 Telehealth Program
- Federal Communications Commission Rural Health Care Program

COVID-19 Related Telehealth Programs

- patient-centered
- protects patients, clinicians, and community from exposure
- allows 24/7 communication between patients and clinicians
- reduces staffing issue
- preserves personal protective equipment (PPE)
- maintains patient-provider relationships during quarantine 
- protects the elderly as well as those who live in very rural settings, are medically vulnerable, or experience limited mobility 


Benefits to telehealth infrastructure

Limitations of telehealth infrastructure 

- synchronous
- asynchronous
- remote patient monitoring

Telehealth modalities

The types of care administered via telehealth include acute, chronic, primary, and specialty care

Areas of care administered via telehealth

- Include options for language interpretation
- Communicate with insurers and payers to determine the availability of covered telehealth and nurse advice line services
- Provide outreach to patients with limited connectivity and technology access, and provide flexibility in platforms to include video and non-video options


Strategies to increase telehealth uptake

In order to safeguard telehealth services, healthcare systems should consider
- Compliance with federal and state regulations, directives, and expiration dates
- Awareness of announcements on HIPAA and COVID-19 by the Office of Civil Rights (OCR)
- Training of staff and healthcare providers in telehealth protocol 

Safeguarding telehealth services

- Opportunities of E-consult: clinician-to-clinician communications
- Opportunities for Remote patient monitoring
- Opportunities for Patient-initiated messaging
- Opportunities for Telephone visit
- Opportunities for Video visit

Opportunities of telehealth infrastructure

This is the first phase of delivering care to patients during the pandemic and transforming the current system to provide care while minimizing infection.
To optimize care, telephone visits and video visits take up a big portion of out-patient care as telephone visits increased 3000% and video visits increasing 1000% between the period of March 16th to April 9th.

Stay-at-home outpatient care

COVID-19 is different from a normal disaster due to the virulence of the virus. Because of this, the demand for telehealth applications increases to manage the standard of care needed to treat patients all while allowing professionals to work remotely during the initial surge of the virus. 

Initial COVID-19 hospital surge

- Patient satisfaction is associated with modality of Telehealth.
- Comparable with in-person visits

Patient satisfaction

- Video conferences or photos can be used for follow-ups after surgery for post-operative complications without patients needing to physically go to the hospitals. 
- Before engaging in a telehealth follow-up program, patients are asked if they prefer to visit clinicals in person. 
- Many elective surgeries have been postponed to the future by the American College of Surgeons. However, preoperative evaluations should still be conducted utilizing imaging, labs, medical history, risks, benefits, and imaging. This information should be discussed with the patient and their family members.
- Videoconferencing can also be used for emergency situations so that patients can potentially avoid entering the ER and being in danger of COVID-19. 


Telehealth in Surgery (COVID-19)

During the COVID-19 era the regular treatment and communication between physicians and patients regarding preexisting comorbidities has been disrupted. New guidelines and safety precautions must be put in place in order for physicians to still treat their patients and treat them through the use of telehealth or other means. While there are a lot of similarities between new communication policies being implemented across different areas of medicine, there are also many differences due to comorbidity specific criteria which facilitates different levels of involvement and communication between physicians and patients.


The comorbidities addressed under this node include:
- Cancer
- Cardiovascular Diseases
- Digestive Diseases
- Elective Surgeries
- Liver Diseases
- Psychological Disorders
- Renal Diseases

Changes to COVID-19 Patient Comorbidity Treatment and Communication

The COVID-19 infection has shown increased death rates among older patients. Relatedly, the majority of healthcare workers, across the world, are over the age of 50 and are at higher risk of getting infected due to interactions with infected patients. In order to safeguard those in the healthcare profession who are at a higher risk of mortality, a restructuring of the healthcare system is necessary, and telehealth is at the forefront of said restructuring. 

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