COVID-19 has resulted in many shifts in our daily lives – at work, at school, and in our doctor’s office. Physical distancing and wearing masks while in public help to prevent the spread of coronavirus and protect our communities. The pandemic has also required us to find new ways to connect with others, including our health care providers.

Because health care services are vital to keeping Vermonters healthy even when we are limiting our contact with others, phone and video “telehealth” visits are on the rise across Vermont. In a recent statewide survey conducted by OneCare Vermont, health care providers overwhelmingly responded that they are providing telehealth services to patients during the public health emergency.

Health care providers have quickly adapted to this technology and are using it to care for patients when they are sick and when they are well. Before the public health emergency, annual wellness visits were typically conducted in person. While we are distancing, providers can still offer wellness visits using telehealth by adapting their visit flow. For example, patients can provide key information prior to the visit through their doctor’s Patient Portal. Completing this information before the visit gives the care team time to review it, maximizing the opportunity for the patient to share questions and concerns with the provider during the visit.

Medicare has implemented significant changes to support providers who are performing telehealth annual wellness visits. A few of these changes include:

• Annual wellness visits may be conducted by audio only
• Patient reported blood pressure and weight are acceptable
• Professional claims billed for non-traditional telehealth services dated on or after 3/1/2020 are paid the same as ‘in person’ visit.

While it has long been the case that medical doctors (MDs), doctors of osteopathic medicine (DOs) and advanced practice providers perform annual wellness visits, with appropriate education, registered nurses (RNs) and licensed practical nurses (LPNs) also provide this service. UVM Medical Center and Dartmouth-Hitchcock Medical Center have developed successful, robust programs for RNs to perform these visits. In St. Albans and Bennington at clinics owned by Primary Care Health Partners, LPNs have provided annual wellness visits for years.

To better understand the impact of providing annual wellness visits during a pandemic via telehealth, we spoke to Dr. Norm Ward, OneCare chief medical officer. Below is an edited version of our conversation.

How does intake for Annual Wellness Visits work virtually?

“Many people have blood pressure machines at home, they have scales to measure their weight. We ask the patient their weight, blood pressure, and record it. The patient’s height is generally in their electronic medical record (EMR) so we can figure out their BMI. It’s not common for patients to have devices to measure their oxygen saturation, but often folks with chronic respiratory illness do, and thus can give us their O2 saturation reading. “

What kind of planning is required to schedule an Annual Wellness Visit via telehealth?

“Clinic staff planning includes health risk assessment questions and Social Determinants of Health questions – this screening can be done prior to the visit through the Patient Portal – EMR access point.”

How have your patients responded to these telehealth visits? Do they like them? Do you like them?

“People welcome the convenience – they feel safe because they feel they are reducing their exposure to other patients who might be sick. In general, people overestimate the value of the physical exam in an Annual Wellness Visit. A physical exam may reveal new symptoms, but a large part of the visit is to review medications, dosage, or offer advice about a new medication. If the visit is by video, Range of Motion can be done virtually, not so over the phone. So that is a barrier—that not everyone has video capability. However, now that we have the ability to conduct these visits using just audio, it is improving annual wellness visit access overall. Just talking to the patient provides opportunity to assess and amend treatment regimens.”

So you are seeing important benefits from telehealth visits?

“Before the option for video, everyone had to show up in person. Telehealth really has opened up opportunities for patients in terms of access. Frequently, transportation was an issue, the weather, traveling a distance. A dilemma for those of us in the field has been calculating the total cost of being seen in the office. In the ‘old days’ a patient had to take off time from work, travel to the appointment using resources such as gasoline and wear on their vehicle. That’s a cost to both the employee and the employer. Then the patient arrives for their appointment and they have to sit and wait! If we do more visits by audio/video, everyone benefits, the dollars saved by society in terms of wasted time and energy is a plus. Some other benefits to telehealth outside of annual wellness visits are:

• Post-op care – the surgeon wants to assess the wound. Video telehealth would be a huge time savings for patients having this type of visit.

• People in nursing homes/assisted living/congregate housing – Support and Services at Home (SASH) or Home Health could assist the patient’s participation in this kind of visit. Their assistance could result in a very high quality video visit.

• Dialysis – the provider ‘beams in’ for a visit with the patient while they’re receiving dialysis. This would make one less medical trip necessary for this population of patients.

• Adolescents – telehealth is very convenient with this age group for their annual wellness visit and other visits. Their comfort and familiarity with social media may allow them to share more information via phone or video than they might in an ‘in person’ visit.”

What are some challenges you’ve encountered using telehealth?

“Cognitive assessments can be difficult by phone. However, you can certainly, for example, ask the patient for three words or ask them to name 15 animals in a minute. By video you can ask the patient to draw the face of a clock and hold it up to the camera. Even the mental status exam is adaptable to video. So there are ways to make it work.

The potential downsides might be the inability to do point of care testing, blood work, urinalysis, EKGs. Also, well-child visits could be challenging. Pediatricians are reluctant to do visits by audio & video—although there is potential with video. An issue is the child’s vaccines are often scheduled during well-child visits, so it’s a mixed bag there.”

What’s the role of support staff in telehealth visits?

“Rooming staff still do chart prep, review the medication list, request completed documents from the patient using the EMR portal. They room ‘virtually’ by phone.”

What are your thoughts about the telehealth process post COVID-19?

“Will it stick? Depends on what Medicare decides to allow. There are a larger number of allowable visits on video–some visits are ok for audio only; psychiatric treatment comes to mind. It will be a policy issue–in Vermont the outcomes will be guided by the legislature. CMS will be guided by the Federal Government. A lot will depend on feedback from providers.”

Can you offer any recommendations?

“Advice to other providers? You have the ability to send an email link to a patient to sign on to a video connection. Providers must have a platform (Zoom, Doxy, etc.) to communicate—as long as the patient has a phone/camera/email, communication is possible. Many EMRs have video capability built in.
Also, the provider must learn how to optimize the quality of the interaction—position yourself facing the light so your face is not in shadow. Don’t sit with a window in the background. Speak more slowly to allow for transmission delays. Give people the latitude to tell you what’s wrong, what’s bothering them. Take the time you need to communicate effectively with the patient.”

More About Annual Wellness Visits

Annual wellness visits are a critical component of preventive health. Providers and patients use these check-up visits to review medications, chronic conditions, and vital signs such as blood pressure, height, and weight. Benefits of these visits include:

• Personalized care planning
• Enhanced quality of care
• Focus on Illness prevention
• ‘Non-urgent’ setting for providers and patients to connect
• Platform to address gaps in care
• Opportunity to improve health literacy
• No co-pays for the patient