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Telemedicine in the Time of COVID: Conversations With Dr Green

Telemedicine use has grown significantly since the beginning of the pandemic. Lawrence Green, MD, interviews Jules Lipoff, MD, chair of the American Academy of Dermatology’s Teledermatology Task Force, about governmental changes to telehealth, the benefits and challenges of telehealth, and the AAD’s toolkit in this podcast.

Dr Lipoff is an assistant professor of clinical dermatology at the Perelman School of Medicine and the chair of the of the American Academy of Dermatology's Teledermatology Task Force.

Dr Green is the section editor of The Dermatologist’s Psoriasis Center of Excellence, clinical professor of dermatology at George Washington University School of Medicine in Washington, DC, and on the National Psoriasis Foundation Medical Board.

AAD Resources:

Teledermatology Tool Kit

Practice Management


Dr Green: Hi, I’m Dr Larry Green, section editor of the Psoriasis Center of Excellence for The Dermatologist, and clinical professor of Dermatology at George Washington University School of Medicine in Washington, DC. Today, we’re lucky to have Dr Jules Lipoff who will join us for a discussion about the use of telemedicine during the COVID-19 pandemic.

Dr Lipoff is an Assistant Professor of clinical dermatology at the University of Pennsylvania, Perelman School of Medicine, and the chair of the American Academy of Dermatologists, Teledermatology Task Force. Dr Lipoff, thank you for joining us.

Dr Lipoff: Thank you for having me. It’s a pleasure.

Dr Green: All right. Let’s just get right into it. Start by telling me how the COVID-19 pandemic has affected dermatology, the University of Pennsylvania, and what you guys are doing to further our knowledge about COVID-19 and dermatology.

Dr Lipoff: I think at Penn, just a microcosm of everything that’s going on in the country. We have closed our clinics effectively except for absolute emergencies and we are trying to find ways to deliver care and keep our clinic afloat that both maintains good care for our patients but also maintains social distancing to minimize transmission of virus and flatten the curve.

Like a lot of places, we have changed the way that we’re practicing in-person, which is mostly not practicing in-person, and tried to expand and update our telemedicine programs both with video visits and using what we call store-and-forward or remote photo and written communication sharing through our EMR platform.

Dr Green: Wow, really interesting. Penn is really ahead of the curve in that respect. You guys are seeing some dermatologic manifestations of COVID-19, I’ve heard.

Dr Lipoff: I haven’t personally seen too much because I’m not doing in-person care. I have done some virtual visits and I have had at least one patient who had pernio, who I suspect has COVID but did not have a confirmatory test, but this is part of the other work that I have been doing also with the ad hoc COVID-19 task force for the AAD.

That’s led by out-going president, George Hruza, and many excellent bright members and I feel very fortunate to be a part of that team. Esther Freeman who is on this team, she helped lead the effort to design a registry for dermatologists and other physicians around the world to enter in information about cases of dermatologic manifestations on COVID patients.

I’m part of that team, part of that writing group trying to evaluate the cases we’re seeing. We’re definitely aware of these cases of pernio or pernio-like lesions, especially on the feet, the toes, and the hands. That’s the majority of the manifestations that we’ve seen reported thus far, but many other things that are being reported.

We still have to collect more in the way of pathology and confirmed cases because a lot of these are suspected cases of COVID but not confirmed. Even there are some cases that tested negative but we don’t know if this is just a late manifestation so they no longer test positive or if there might be some other explanation.

Dr Green: So interesting, and the AAD registry I’m sure it’s so important to obtain as much information as we can as for dermatologists. Thank you for participating and being such a big part of that.

Let’s delve into some telemedicine. Can you just explain to me some of the most important organizational and governmental changes that have assisted in helping get the widespread use of telehealth during this COVID-19 time?

Dr Lipoff: Yes, I’d be happy to. Prior to this crisis, telemedicine has been shown to be effective and reasonably equivalent to in-person care in a lot of settings. We think of it as not different care, but just a different method to deliver the same care.

That said, we haven’t really scaled it up or implemented it that much relatively, because of certain barriers. The number one barrier has been lack of reimbursement. Most payers have paid quite poorly if at all, and so that has limited physician’s ability to do this. There have also been licensing restrictions. In general, if you don’t have a state license for where a patient is physically located, then you’re not allowed to take care of them. Then there are other aspects, like it needs to be a HIPAA-compliant platform and all this sort of thing.

Well, a few weeks ago, CMS, the Center for Medicaid and Medicare Services, announced relaxation of many of these regulations. For one thing, they announced that Medicare will reimburse virtual video visits at the same rate as in-person visits.

That’s a bit of a game-changer because that was true only in a selected setting in certain rural situations or seeing patients in certain clinic scenarios. That is really changing and most payers are following suit and agreeing to pay at those rates as well. That major barrier is at least temporarily for the duration of this crisis, relaxed.

Also, state licensing has been loosened significantly. There’s reciprocity right now through most states. There are individual state laws that you have to pay attention to. For instance, in New Jersey, I had to fill out a quick thing for a temporary license online.

Then HIPAA-wise, the government announced that as long as providers are practicing telemedicine in good faith to deliver care for their patients, they will not be incurring any penalties for using non-HIPAA-compliant methods of telemedicine.

It is legal effectively to use FaceTime or Skype to see your patients, even though that may not meet the stringent encryption criteria of HIPAA. Certainly, we wouldn’t encourage that, HIPAA-compliant platforms are better, but as a temporizing bridge to get there, it’s totally fine.

So now you can do video visits and get paid. You can see patients across state borders, and you can even try using platforms that are not necessarily HIPAA-compliant. In a lot of ways, we’ve been pushing for loosening of regulations on telehealth for years and years, and in about two weeks, it loosened more than it had been loosened in probably 10 to 20 years.

The government is explicitly saying they want to encourage access to health care and we’re going to see, I think it’s going to set some really interesting precedents. I think a lot of people have been resistant to using telemedicine because of preconceptions they have about it, but they haven’t personally really piloted it. Now everyone is being forced to try it. And they’re starting to see the benefits of how it can work and also just understand the more appropriate settings for it.

Dr Green: It’s all amazing how the COVID-19 pandemic has loosened things up and the government’s loosen things up for us to help us all better understand how telemedicine can or cannot work in our practice. You mentioned some of them, but what are some other benefits of using telemedicine from both our perspective and then from the patient perspective?

Dr Lipoff: Certainly, there’s all kinds of benefits. I would say, namely, it’s about allocating resources. Whenever you can manage a patient with telemedicine, you’re not only helping that patient, you’re opening up access in-person to someone else.

There’s only so many resources for in-person right now, especially, there’s only so much personal protective equipment. So, for every patient you prevent from seeking emergency care, that can be handled by telemedicine, not only are you helping more people, but you’re saving more resources, which helps everyone.

I think in the long term, we may find that there are a lot of patients that will be better served remotely. Especially, you can imagine, say, an elderly patient coming in for maybe a spot wound check from hours away. Prior to this, a clinician may only get paid if they see them in person. That push things to have to be done in person.

But, if you can visualize something adequately and you’re saving that patient, the time, the money, the risk of traveling, the risk of in-person contact, I think clearly telemedicine can be better care. For a lot of things, it’s going to help us allocate our time more efficiently.

Another more common thing would be like an acne follow up. A lot of patients on medications doing well, even like Accutane follow-up, so you can see them, you can talk to them. Coming in person, it’s not necessarily really important.

There are certain things, however, that you really can’t do remotely. You can’t do procedures, at least not yet. You can’t do biopsies. We can’t do full skin checks, or at least not as easily. I think with time, and building up certain systems, you might be able to incorporate more of these things more easily. But when you separate out what you can and can’t do in person, it allows you to use your in-person clinics more efficiently for the people who really need to be there.

Dr Green: All so interesting. With the isotretinoin, you mentioned, it is really interesting, there’s a lot said now about not needing to do labs every month when patients come in anymore, especially if they’re stable in terms of their lipid profile and liver functions. Telemedicine offers an opportunity there, like you mentioned, when the patient doesn’t need labs, necessarily.

Let me flip and ask about some of the challenges of using telemedicine from our perspective and from the patient perspective as well.

Dr Lipoff: It is challenging. Anytime that you’re trying to change the way we practice, there’s going to be a lot of growing pains. Initially, just technological savvy, if you don’t own a smartphone, you’re probably someone who’s going to have trouble figuring this all out just because you have to learn how to adapt, how to use technology, how to get people on the phone.

Dr Green: That can be a problem for some of the elderly, like you mentioned earlier, who could otherwise be amenable to using telemedicine.

Dr Lipoff: I think the elderly certainly can use it, but they’re going to be more elderly people who have problems with this than younger people. It depends on certain connectivity. There’s definitely structural issues here, certain race, certain jobs, certain housing settings, you may or may not have access even to good WiFi or Internet, may have to be still working even in this setting.

Telemedicine does have a lot of potential to bridge some of these access gaps but there are still some larger issues that we’re going to be fighting against that existed before this problem.

Dr Green: Aright Jules, any other challenges you can think of on the patient side or provider side?

Dr Lipoff: I think we still have the mechanics of like, how do you run a clinic by telemedicine? How do you integrate that alongside in-person care? If you didn’t have this crisis, you can imagine that you could have a clinic of in-person patients, but put in some virtual patients in the queue so you just sit in your office and do it for those.

There are a lot of challenges in just, how do you decide who needs to come in and who doesn’t? It is challenging to ask patients to adapt. I think it’s up to us the providers to adapt and to understand, how do you decide what is urgent and what is not urgent? That is up to any provider’s discretion and I think it takes time to figure that out.

Certain cases, we’ll all agree that a Stevens-Johnson patient needs to come in urgently, but what if someone has an abscess? Is that something that you can manage remotely or do they have to come in for an incision and drainage?

We’re trying to avoid all unnecessary visits, but it can be difficult in case by case. That’s why it’s been challenging advising people how to make those decisions because it really is dependent on the individual patient.

Dr Green: And the doctor as well, their comfort, what they think is best. It’s very interesting. You’re on the forefront of this. It’s all going to be worked out and what seems to be best, and I’m sure things will be published on that in the future.

Let me switch to asking about telemedicine platforms. What considerations should dermatologists keep in mind when selecting a telemedicine platform? I know a lot of my physician colleagues here in the DC area are using Doxy, basically because it’s free, but they say it’s not that great.

Let me have a follow-up on that. Does the American Academy of Dermatology have any guidelines or recommendations on selecting a platform?

Dr Lipoff: We have a position statement about general considerations for what you should be looking for when performing telemedicine. In our teledermatology toolkit, which is part of the AAD website and a part of the COVID-19 information, which is very useful, we do have some general guidance. We have posted, we haven’t endorsed anything, but we’ve posted a number of vendor platforms that are offering their services for free. Something like is a good consideration.

The most important thing is, I’ve been telling people, “You want to get your clinic’s lights on first, then worry about having the best light.” That’s why it may be reasonable to consider FaceTime, or Skype, or Google Hangouts, one of those, but we want to promote the best quality of care.

A HIPAA non-compliant is not going to be quite as high quality as HIPAA-compliant as far as respect to patient security. You can use some of those platforms if you need to. Of course, a lot of providers may be hesitant because it’s a little harder to figure out how to do FaceTime, for instance, without giving out your personal phone number.

But I would say one of those free platforms, if your electronic medical record offers something that can be integrated automatically, that is also helpful. Because a lot of these platforms, you’re doing the visit over one platform, but you still have to document in your electronic medical records secondarily.

Dr Green: That’s true, and looking at your EMR is a great idea to see what they have. Let me ask you, say we have someone makes a telehealth appointment, can you walk us, dermatologists, through what you suggest we do in terms of seeing the patient, documenting, and then billing, or coding?

Dr Lipoff: As far as seeing the patient, you should try to organize your staff and whatever workflow works for you, and different private practice and academic settings will be better suited to different models. But, in general, having an appointment time that’s agreed upon so that they can log on to whatever meeting, or conference, or however you’re doing it.

Then, you do need to make sure the patient is aware that this is being billed to the insurance as a regular visit. There may be a copay, although I actually didn’t mention this before that CMS said it was OK to not collect a copay, if necessary, it’s another relaxation of regulation. Making sure they’re aware of all that and documenting either the medical complexity and the time. Then, you can bill it actually the same 99201 and 99215 type of visit with the proper modifiers, which is, I think a 95 modifier.

For very specific codes for different types of visits, including telephone only, and store-and-forward visits, I would direct you to look at the teledermatology toolkit because it has all the up to date information. It is still changing a little bit here and there and I wouldn’t want to tell you the wrong thing. But, I think full transparency to let patients know that this is what’s happening.

Dr Green: I think I can’t emphasize enough just like you are to go to the American Academy of Dermatology website and look up the teledermatology toolkit. So helpful. What about patients who aren’t so tech-savvy? Any tips on walking them through the telehealth platform?

Dr Lipoff: I think you have to be very clear with them. Ask them what devices they have that have microphones and cameras. They may not have one. Which one are they comfortable with? Phone, laptop, tablet?

If it’s difficult to do a video, you know you can do a very good visit by telephone alone for a lot of patients. You can do visits by telephone and pictures sent through whatever platform or electronic medical record you may have, or while HIPAA non-compliant is acceptable, even by email.

The important thing is that we are getting people the access they need first, and with experience, we’ll get to see what works for each individual practice, and then we’ll build on that. But there are going to be some patients that can’t figure this out. You just got to do the best you can. At least you can try to manage it by telephone because I think all patients are able to use the telephone.

Dr Green: Very good. So helpful, Dr Lipoff. Any other thoughts or comments you want to add or advice to give to our fellow dermatologists about teledermatology or telehealth or anything we’ve discussed?

Dr Lipoff: I would say a few things. First, to be open-minded about how telemedicine works and can be in your practice, and to be patient and not get frustrated or expect things to work immediately.

There are a lot of really smart, academic, achievement-oriented people who are perfectionists in dermatology, so we’re not used to things not working at first, but it’s a process. You have to do to see what’s working, what’s not.

Don’t commit to paying for a yearlong subscription to some platform without trying something free first to see what actually works for you. Don’t invest a lot first. Just try things out.

Try to be patient and learn. I think this should be a learning experience, not just for this crisis, but I think it’s going to set some really interesting precedents long term. I think telemedicine is going to end up being much larger part of our practices in the long term because of this huge event, and I think for the better.

Dr Green: Thank you. Thank you, Jules. Thank you for taking the time and for you, the listener, to listen to all this. I hope it’s been helpful.

Jules, I can say, as a dermatologist, I appreciate all you’re doing to help us through this crisis and help make telemedicine part of what not just today but something for the future for all of us. Thanks again and look forward to talking to you in the future at some point soon.

Dr Lipoff: Thank you.

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