Clinics switch to virtual patient visits to limit coronavirus exposure

Dr. Tim Buchman, director of the Emory Critical Care Center and Cheryl Hiddleson, a registered nurse and director of the Emory eICU (electronic intensive care unit), stationed in Australia, talked to patient Jean Vargas at Emory Johns Creek Hospital in 2018. File photo

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Dr. Tim Buchman, director of the Emory Critical Care Center and Cheryl Hiddleson, a registered nurse and director of the Emory eICU (electronic intensive care unit), stationed in Australia, talked to patient Jean Vargas at Emory Johns Creek Hospital in 2018. File photo

For the first time in his long career as a family care practitioner, Dr. Andrew Reisman had to fight the urge to put his hands on a sick patient.

The Gainesville doctor couldn’t touch his patient’s neck to check for a swelling of the lymph nodes that signals a bacterial infection. He couldn’t check for back pain that could indicate something worse: appendicitis, a kidney infection or maybe just dehydration.

Yet, he was able to make an appropriate diagnosis. Using his iPad, Reisman peered inside the back of the patient’s throat for a close-up image of the patient’s tongue, the sides of his mouth, his throat and gums. All this, Reisman accomplished on Wednesday, while his patient was under the flashlight of an iPhone.

» COMPLETE COVERAGE: Coronavirus in Georgia

“For not being able to put my hands on a patient, it’s been better than I thought it might be,’’ Reisman said. “I’m pretty impressed.”

Up until now, Georgia medical professionals say many of their peers have been reluctant to use telemedicine for fear that patients may not receive appropriate care, and their confidentiality could be violated, in the virtual world. But much of that apprehension has taken a back seat to the public crisis created by the spread of the coronavirus, amid concerns about limiting patient exposures to the infection and ensuring enough doctors and nurses are available to focus on the critically ill.

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An assortment of roadblocks, including medical board rules and federal reimbursement restrictions, also stood in the way of virtual encounters between medical professionals and their patients. Then, only days ago, Georgia’s Composite Medical Board responded to emergency declarations by government leaders by adopting new guidelines from the U.S. Department of Health and Human Services. Now, many physicians can prescribe medications and conduct physical examinations without an in-person medical evaluation using Apple FaceTime and Facebook Messenger video chat, Google Hangouts video or Skype. Providers who use telehealth also now can be reimbursed for the encounters after a loosening of rules by the Centers for Medicare and Medicaid Services.

Meanwhile, though hurdles still remain that limit use for the elderly without cell phones and those with no access to broadband, a growing number of providers across the state are turning to telehealth as Georgia's cases of coronavirus continue to climb.

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At the Atlanta VA Medical Center, some physicians are switching over to telehealth to confer with patients, an official told the AJC. VA outpatient clinics are open for telehealth appointments only.

In recent days, other health care providers delivered a steady stream of emails to patients, inviting them to live chats on various apps for any device with a microphone and camera, assuring that virtual visits comply with state and federal confidentiality rules.

“NEW! Telehealth Virtual Medical Visits are Here!” one doctor’s office in north Atlanta announced on Sunday. “You can get the specialized care that you need without risking your health.”

An even deeper loosening of restrictions is on its way. CMS is expected to soon issue revised guidance that allows an array of medical screening exams to be delivered in the virtual world, some medical providers told the AJC.

Advancements in medicine

In some ways, telemedicine could enhance the ability of physicians and nurses to better evaluate patients.

For several years, doctors and nurses at Emory Healthcare have used state-of-the art medical equipment that enables them to look more closely at patients.

A high-resolution camera provides details that that cannot be seen by the naked eye. With it, Dr. Timothy G. Buchman, the telehealth program's medical director, can easily count the number of eyelashes on the upper eyelid of a patient. Buchman, speaking only as an individual and not for any institution, also has at his disposal other high-tech devices. For example, using a Doppler ultrasound, Buchman can hear the blood flow through the arteries and veins of a patient who might be experiencing a blood clot in the leg.

What doctors and nurses worry about are the limitations of telemedicine, which can be extensive unless the physician is well trained and has a support staff to do additional legwork.

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“You can’t touch a patient,’’ Buchman told the AJC. “You can’t feel how cool the foot is. You can’t feel the sweat under somebody’s arm pits. You can’t use other senses that are so important to evaluating a patient.”

He relies on a team of professionals to provide him with this information. He is aided by nurses and hospital staff who are at the patient's bedside when he communicates with them. It's then easier to fill in the gaps for questions that depend on senses like touch or smell.

For decades, paramedics and emergency medical technicians have provided a similar support for physicians in the emergency room. These healthcare workers have practiced a form of telemedicine, using radio communications to consult with doctors and nurses on some patients.

The U.S. military, for just as long, has depended on telemedicine to deliver care across the globe. Even astronauts, more than half-a-century ago, used telemedicine equipment to stay in touch with medical teams on Earth that monitored their heart rhythms while they traveled in space and landed on the moon.

Now, healthcare professionals say the COVID-19 epidemic is likely to spawn more telemedicine advancements.

“It will be rapidly expanding and, no doubt, this is going to be the jump start,” said Dr. James Augustine, an emergency room physician in Fulton County and chairman of the National Clinical Governance Board for emergency healthcare professionals. “Whether it be the plagues or the Spanish flu, each of these significant diseases have changed the whole of society.”

Reisman, the family care physician, said his colleagues on the board of the Medical Association of Georgia have been talking about how to create policies that support physicians who want to use telemedicine to reach patients.

There are many unanswered questions, including concerns of patient privacy and meeting the standard of care.

“The purpose of the board is to protect patients and make sure medicine is being practiced appropriately,’’ said Reisman, who is a member of Gov. Brian Kemp’s coronavirus task force. “All kinds of considerations need to be in place to make sure it is safe and effective.”

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