Amidst the social sea change thrust upon us by the coronavirus disease 2019 (COVID-19) pandemic, many of the activities that we historically performed in person have moved to virtual environments. Working from home, attending school from home, shopping from home—these have all been new for many and greatly expanded for most others. In fact, our move from in-person to real-time virtual activities has been in progress for at least 100 years, when telephones began to appear in ever greater numbers of homes. But that once comparatively leisurely march took a quantum leap over this past year.
Nurse practitioner (NP) educators have been accustomed to working virtually for some time. Most of us in clinical practice, after spending relatively little of our time working virtually, were called upon to quickly adjust to a number of telehealth modalities. Adoption of those same modalities, however, like our health care system itself, has been uneven and depends on a number of factors, including your specialty, where you work, and who pays the bills. Notwithstanding, the evidence on the use of telehealth clearly supports its practice and expansion. Pandemic-related mandates to socially distance have pushed telehealth into new sectors of the health care sphere, and most of us have now had telehealth experience, both as providers and maybe also as patients. Will, as the saying goes, the necessity of the pandemic become the mother of invention? Is broad use of telehealth—to overcome barriers, reduce costs, and increase access—here to stay?
–Donald Gardenier
YES
By Jennifer Ballard-Hernandez
Jennifer Ballard-Hernandez, DNP, AACC, FAHA, FAANP, is the cardiology clinical nurse advisor to the office of nursing services for the Department of Veterans Affairs central office. She is field based at the Tibor Rubin VA Medical Center in Long Beach, California, where she works as a cardiology nurse practitioner. She is a member of VA virtual care specialty care expansion workgroup. Dr. Ballard-Hernandez serves on several national committees and is currently appointed to the federal cardiology section leadership council of the American College of Cardiology.
Telehealth has emerged over the last 20 years as an innovative strategy to deliver the right care, at the right time, to the right patient, in the right setting. Virtual care is delivered through the use of video conferencing technology and is often coupled with remote patient monitoring to improve the physical assessment. Although the greatest strength of telehealth is in improving health care access, data continue to emerge that highlight how telehealth improves outcomes, reduces waiting times, reduces costs, and improves patient and provider satisfaction. NPs continue to play an integral role in telehealth delivery and are perfectly positioned to promote its use and expansion.
Although the COVID-19 pandemic has catapulted the benefits of telehealth into the national spotlight, the Veterans Affairs (VA) Healthcare System has been an innovator and leader in the virtual care arena as early adopters of telehealth implementation and use since the late 1990s. As the largest health care system in the United States with widely diverse operating environments, the VA operates hospital facilities in every state and the District of Columbia, including 170 VA medical centers and 1,061 community-based clinics. There were 196,116 video visits to veterans in their homes or at other off-site locations during the week of November 15 to November 21, 2020. This is a 1,653% increase in weekly video visits from the end of February 2020. Many of those visits were delivered by NPs. The peak total number of daily video visits to veterans in their homes or at other off-site locations is more than 41,000 per day nationwide.
The VA Healthcare System has proven the ability to implement telehealth as a sustainable modality for care delivery. Telehealth provides timely access to primary care and specialists, appropriate use of resources, access to care, especially in high-risk populations, and the ability to coordinate care in the community. The success of telehealth care delivery in the VA Healthcare System can be used as a model to overcome many limitations in the private sector health care systems.
NO
By Margaret O’Donnell
Margaret (Peg) O'Donnell, DNP, FNP, ANP B-C, FAANP, is a primary care provider and clinical director of advanced clinical providers at Northwell Health in Lynbrook, New York. She is also an adjunct clinical assistant professor at Stony Brook School of Nursing in Stony Brook, New York. Dr. O’Donnell has held numerous leadership roles with the Nurse Practitioner Association New York State and the American Association of Nurse Practitioners and has spearheaded many programs designed to promote our profession and advocate for excellence in primary care.
According to the Centers for Medicare and Medicaid Services (CMS), more than 24.5 million Medicare beneficiaries received telehealth services between mid-March and mid-October 2020. Before the pandemic, there were only about 15,000 Medicare telehealth visits per week. After the initial surge in the northeast, decreasing prevalence and prevention guidelines, such as wearing masks and social distancing, allowed many healthy people to feel comfortable with in-person care. However, for those who are not capable of making it to the office, increased home care services, remote monitoring abilities, and telehealth services are a lifeline.
In response to the need for telehealth services, as of December 1, 2020, CMS expanded telehealth capabilities by adding 60 covered services. This is a step in the right direction; however, several issues need to be addressed if we are to look forward to a permanent solution. Before the COVID-19 pandemic, CMS had statutory authority to pay for telehealth only in rural areas. It is still not clear whether telehealth services will continue to be paid in nonrural areas. It is also unclear whether the 2021 CMS fee schedule, which will increase payments to providers for additional time spent with patients, will similarly increase payments for telehealth visits. The pandemic has also brought a relaxation of Health Insurance Portability and Accountability Act (HIPPA) restrictions, and platforms have been used that have inconsistent levels of performance in this regard. Loosening these HIPPA restrictions can open patients up to fraud and abuse. Telehealth has also been a difficult transition for many of our patients, many of whom are elderly and isolated. People need human contact, and I believe if telehealth is to move forward, it must be accompanied by home visits.
Although stakeholders are showing support for decreasing restrictions and incentivizing telehealth, achieving payment parity and standardizing regulations are still needed for broader telehealth use. This evolution exemplifies the unintended consequences that can happen anytime there are changes in our health care system and demonstrates why we, as providers, must remain vigilant and advocate for our patients.
Biography
Donald Gardenier, DNP, FNP-BC, FAANP, FAAN, is an NP in clinical practice in gastroenterology at Eisenhower Health in Palm Springs, California. He is the editor of this column. He may be reached at dgardenier@gmail.com.
In compliance with standard ethical guidelines, the authors reports no relationships with business or industry that would pose a conflict of interest. The views expressed in this column by Dr. Ballard-Hernandez are her own and are not, nor should they be viewed or construed as those of the Department of Veterans Affairs.