On March 18, as the COVID- 19 crisis accelerated, we converted overnight to “seeing” our patients by video. Our journey into telemedicine was abrupt, and there was a steep learning curve.
Our practitioners have a number of interesting, and sometimes humorous, stories to tell. One patient is a rancher, and we heard mooing in the background during the call. We’ve heard chickens clucking and we have seen kids at home in the background.
Our practice is Texas Diabetes and Endocrinology in Austin. We have three offices, 11 endocrinologists, 12 advanced practice nurses, and a physician assistant. We stopped having patients enter the office, which meant that we could no longer do in-office ultrasound, and our ability to continue clinical research was curtailed.
We had installed video cameras on our computers knowing the crisis was coming. Our phones remained open for calls to nurses, yet the office staff and medical assistants had to convert to a completely new way of providing care. Patients were prepped for the visit with a call from the medical assistants the day before letting them know what to expect and how to connect via telemedicine.
We take care of people with diabetes, some of whom use insulin pumps and continuous glucose monitors (CGMs). The day before the visit, the patients were asked to download their pump and CGM data via the web so that we could have the results available at the visit. Patients were also asked to check their blood pressure at home if possible.
We made lots of adjustments to the process early on, and we continue to.
“Seeing” patients via telemedicine has been an essential way to continue to deliver care to our patients with chronic disease. We have seen new patients and continue care for our patients with diabetes, thyroid conditions, osteoporosis, and other endocrine conditions. Delivering care to new and existing patients has been very effective; in some cases, we have been able to deliver better access to care than when the office was open.
We have emphasized to our patients that continuing to manage their chronic condition during this crisis is imperative, that the crisis will pass but their medical conditions continue, and that gaps in care could lead to complications. In addition, the chronic conditions that we help our patients manage, such as diabetes and adrenal insufficiency, increase the risk of complications of COVID-19 or any other infection, so continued care is critical.
We now have more than two months of experience with telemedicine. Many people have gone to their cars to take the call and escape a noisy house or office to have privacy. Our clinical nurse specialist recalls seeing mainly nostrils as people have held the two-way video phone near their face. We’ve seen pets, and some cats have tried to play with their owner’s phones. Some patients don’t have smart phones so at times, we simply have used the audio phone connection.
We’ve found that more than 90% of the care we provide can be done with telemedicine. Clearly, we are not able to examine patients, yet video evaluation can be effective. One patient showed a skin lesion. She was referred to dermatology and the lesion was biopsied. Many medical practices need to examine the patient at each and every visit, but in our practice, we feel that a yearly exam with telemedicine visits in between would be safe and effective.
One of our endocrinologists made a potentially lifesaving diagnosis of adrenal insufficiency in a patient who lives in an outlying area and declined to come to Austin for care but agreed to go to a nearby lab.
We’ve seen a lot of patients who are thrilled to have a medical visit in the comfort of their home or office (or car or corral). Telemedicine has saved our patients from exposure to the coronavirus and has saved them many miles of travel, time, and fuel. We’ve “seen” patients from all parts of Texas. Many of our patients drive in from towns that are 50 to 100 miles away, and we’ve felt especially good about seeing older patients who usually drive 60 miles each way and brave the traffic to get to Austin.
We hope that Medicare agrees to continue the open use of telemedicine. Many insurance companies and Medicare have embraced and even promoted telemedicine to keep the people that they cover safe during this crisis. We applaud them for this. It is our hope that this endorsement of telemedicine will continue after this crisis with development of telemedicine standards.
We shouldn’t go back to an overly restrictive telemedicine environment.
Devaluing telemedicine to pre-crisis payment rates would limit its use, which would be detrimental to patients and to medical practices. Before the crisis, Medicare and commercial insurance carriers valued and paid for telemedicine visits at much lower rates than regular in-person office visits. Also, in most cases, Medicare required that patients be located at a clinical facility during the virtual visit with the practitioner.
We have opened our office to in-person visits gradually in May and June, yet we feel strongly that telemedicine should be an option for our patients in the future. Individuals, groups, and employers likely will seek out insurance coverage that includes robust telemedicine coverage for members. And we feel that commercial insurance carriers and Medicare should enlist physicians in clinical practices to help establish telemedicine standards and expand instead of restrict its use.
Telemedicine has provided us with the opportunity to reach out to our patients safely, conveniently, and with maximum flexibility in these unusual and challenging times. Our patients have told us how much they appreciate this service. We are constantly evolving and improving the services we can deliver through virtual means and we are looking forward to building this as a long-term offering even after the current crisis is resolved.
Telemedicine is ideally suited to offer excellent care to our endocrinology patients. Excuse us, we have to get back to a video-phone telemedicine visit.
Thomas Blevins, MD, MPH, founded Texas Diabetes & Endocrinology in Austin.
Kerem Ozer, MD, is managing partner in the practice.