When the governor of Ohio issued a stay-at-home mandate to help slow the spread of COVID-19, Cleveland Clinic responded by postponing all elective procedures and non-urgent outpatient appointments. Physicians were urged to use telemedicine for routine outpatient visits.
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Fortunately, 25% of Cleveland Clinic’s Endocrinology and Metabolism Institute (EMI) staff had been conducting shared medical appointments (SMAs) and seeing about 130 patients per month virtually for up to a year. This experience, coupled with a telemedicine platform that was up and running, enabled the EMI to convert their outpatient practice to virtual visits in a matter of days.
“The response has been overwhelmingly positive,” says EMI chairman Bartolome Burguera, MD, PhD.
In with the New: Telemedicine
With type 2 diabetes and obesity among the most common comorbidities in patients with COVID-19 and predictors of need for hospitalization and intensive care, protecting these patients and the staff who treat them became a priority. This meant converting non-urgent face-to-face visits to virtual visits as quickly as possible.
As former Director of the Obesity Program, Dr. Burguera had been conducting virtual follow-up visits on patients with severe obesity and limited mobility for months, and had found the experience satisfying. “Patients really appreciate being seen virtually. They find it more convenient, and they appreciate our current efforts to reduce their exposure to COVID-19,” he says.
Similarly, he had recently piloted monthly virtual shared medical appointments (SMAs) in Cleveland Clinic employees with obesity and other chronic medical conditions. When weight loss at six months was found to be similar to that achieved in face-to-face SMAs, virtual SMAs began to be offered as an option.
Making the Conversion to Virtual Visits
The need for rapid adoption of alternatives to in-person appointments poses a dilemma for providers with no telemedicine experience or access to the technology. To buy time, payors approved reimbursement for appointments conducted through a variety of familiar, readily available technologies, including FaceTime, Facebook Messenger video chat, Google Hangouts video, Google Duo, Zoom, Skype and the telephone, in addition to commercially available telehealth platforms.
Medicare reimburses about two-thirds for telehealth visits and less for other technologies, compared to traditional face-to-face encounters.
Kevin Pantalone, DO, FACE, Director of Diabetes Initiatives, and an early adopter of virtual visits, suspects reimbursement for other technologies will be phased out after the crisis passes. “The government wants to make sure billing is done through a structured process, and that health information remains secure. This reinforces the need for providers to adopt using a formal telehealth platform,” he says.
Having the telehealth infrastructure in place allowed the EMI to react quickly. Cleveland Clinic trainers spent about one hour with each physician familiarizing them with the platform and how it integrates with the institution’s electronic medical records system. Meanwhile, support staff contacted patients and offered them virtual visits. Of those contacted, 80% agreed.
Virtual Inpatient Consults
In addition to outpatient visits, EMI endocrinologist Marcio Griebeler, MD, is piloting a virtual inpatient consulting service designed to minimize unnecessary contact between consultants and exposed patients and prevent the spread of infection to patients hospitalized for non-COVID-19 related illnesses. The practice also helps avoid unnecessary use of personal protective equipment.
Three types of remote inpatient consults are provided:
- Virtual face-to-face encounters with hospitalized patients conducted via computer or smartphone
- Phone consults facilitated by a nurse or other bedside ancillary staff member, who communicates with the patient.
- Peer-to-peer e-consults that do not involve the patient directly. These include a consultative chart review and provider-to-provider communication via documentation within a shared electronic health record. A conversation between the consultant and primary physician occurs when it is felt to be necessary.
These programs are currently being piloted on main campus and at two regional hospitals.
Face-to-Face Care Will Remain Important
Today, 90% of EMI patients and 100% of SMAs are conducted through virtual visits. New patients and those requiring a biopsy, procedure, surgery or medication infusion continue to be seen in person.
“I’m a true believer that being face-to-face is very important for the first visit. The element of personal touch, direct face-to-face communication and the ability to conduct a physical exam are important when establishing a patient-physician relationship,” says Dr. Pantalone.
Most follow-up visits can easily be conducted via virtual visits. However, there are limitations, since virtual visits limit the senses to sight and hearing.
“You can’t smell infection or feel warmth or other abnormality on a virtual exam. Nor can you obtain vital signs without additional technology or read body language through a computer,” he adds.
These limitations had to be overlooked in the current pandemic, and both new and established visits are being scheduled virtually. When the pandemic subsides, the clinicians will decide which patients should be seen face-to-face.
A Positive Experience
Going virtual allowed the EMI staff to contact all patients ages 60 and older with a hemoglobin HbA1c > 9% seen at Cleveland Clinic within the past year and offer them a virtual appointment to discuss their diabetes management. “We feel the need to do everything possible to make sure patients with diabetes control their HbA1c and associated risk factors during this pandemic,” says Dr. Pantalone.
Although the endocrinologists are confident telemedicine lends itself well to the management of chronic medical problems, an assessment of how virtual visits compare with face-to-face care for obesity and diabetes is underway.
One surprising benefit of virtual visits is the brevity of appointments. “They last less time. I know my patients well, having seen them for years, yet in virtual visits they get to the point much faster,” says Dr. Burguera. This leaves time for dictating encounter notes before the next patient appointment.
Virtual visits also allow the staff some flexibility to work from home. “We don’t have to drive to the office every day to see patients, so it’s a tremendous opportunity to improve our quality of life,” he says. “The possibility of increasing virtual visits is one of the few things from this pandemic that are good.”