Spanning Social Distancing: Telehealth in O&P Gets a Jump Start

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By Judith Philipps Otto

The COVID-19 crisis has drastically changed our world on personal, professional, social, politicalalmost alllevels. Because the unknowable extent of the evolving changes still lies ahead, more O&P professionals are turning to telehealth to help resolve patient care issues created by safe distancing and self-isolation guidelines and restrictions.

Given that the discipline requires face-to-face interaction with patients during the process of measuring and physically fitting them with devices, is it even possible for orthotists and prosthetists to perform their patient care services remotely?

While most agree that telehealth offers benefits relative to health, safety, and patient convenience, they also agree with the American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC) position that "due to the hands-on nature of O&P care, providers must recognize that elements of the services they provide cannot be accomplished virtually."1 And the benefits of telehealth don't come without risks, experts warn.

What can be done via telehealth, and how cautiously, are questions we asked O&P practice owners, consultants, policymakers, and advocates.

Voices of Experience

Despite being unfamiliar with telehealth, Amy Mehary, CP/L, FAAOP, M-Power Prosthetics, Dallas, made the decision to try it.

"Just before we went on shutdown, I saw it coming and thought we'd better get prepared. We started setting up the Zoom e-visits on March 13, but they really weren't that well received."

In early April, M-Power decided to launch a more traditional telehealth program, which allowed HIPAA-compliant consults over a smart phone, landline, or on a laptop.

"We're trying to meet our customers with whatever technology they're comfortable with. It was important for us to find something that you could do on a regular telephone if the patients preferred it."

Their telehealth visits are limited to consults, preliminary evaluations, and follow-ups.

"If after that consult, it's determined that we need to see them in person for an adjustment, we're making that call. But we're still doing deliveries and casting with face-to-face patient care episodes."

As the crisis abates and restrictions are relaxed, Mehary anticipates making further adjustments to accommodate a busier workload. But for now, "We're focusing on what we can do this week, and trying to get through this with strengthened relationships," she says.

"I think telehealth might be something that we maintain in our practice. I thought it might be cost prohibitive, but it's relatively low cost; and it adds value to our patient care experience."

A Step Ahead Prosthetics, Hicksville, New York, has been providing remote services for years via telehealth. Erik Schaffer, CP, president, says he is stunned by the increase in his deliveries to global patients in need who are unable to get care and treatment elsewhere.

He reports seeing large numbers of self-pay patients from as far away as Australia and Egypt. "People are just desperate and willing to pay for things."

Although serving regional patients who send devices for service is business as usual for Schaffer—who is available to them by phone, Skype, Zoom, FaceTime, or other vehicle—"opening it up to others has triggered an overwhelming response from people who are stuck in their homes in other countries, where they don't have access and didn't know I was available," he explains. "They'd just go as many as five years with stuff broken—holding it together with duct tape to get themselves by; now they're aware they have this access and can have things mailed to them."

Schaffer stresses that all work is carefully identified, quantified, 100 percent compliant with Centers for Medicare & Medicaid Services (CMS) requirements, and "documented to the fullest extent of that word."

Although CMS acknowledges that when an item is sent to a patient remotely and they sign for it, it's equivalent to a delivery sheet, Schaffer also backs it up with patient signatures on virtual delivery sheets.

"Just play by the rules," he advises, "and it will all work out."

Watch Your Steps as You Wet Your Feet

 Lesleigh Sisson, CFom, founder of O&P Insight, counsels O&P practices. She points out that telehealth benefits O&P providers not only by facilitating connections with patients, but by allowing physicians to use telemedicine visits to create and share their notes to substantiate what providers are doing.

When the CMS 1135 waiver was announced on March 6, enabling Medicare to pay for office, hospital, and other visits furnished via telehealth across the country, some O&P providers believed they could start billing for telehealth visits, Sisson says. "That's not the case. We can't bill for our time unless we're making adjustments; we can't make adjustments unless the patient is in front of us. We can do virtual follow-ups to see how patients are doing, and do initial consultations, but not a thorough evaluation." 

ABC guidelines are clear that all custom-fabricated orthotics and prosthetics must be fit in person, she notes.

Can clinicians mail the devices, then do a telehealth visit? Sisson calls this a gray area. "On some of them—no, you can't. By policy, especially for Medicare, you have to have an in-person delivery appointment. Some companies are exploring if it might not be possible for a long-term wearer of the device, however.

Sisson shares an essential checklist for those considering using telehealth in their practices:

  •  Integrate a HIPAA-compliant telehealth platform, such as Zoom or Ring Central
  • Develop policies and procedures for your office that take into account CMS, Medicaid, ABC, and private guidelines
  • Train staff
  •  Communicate with patients regarding your telehealth services
  • Develop and use written patient education and instructions for use and care of all devices
  • Document every encounter thoroughly and promptly

"Policy is silent on some of these points, and there are no clear guidelines or a national standard that identifies which types of devices that could be fit via a telemedicine visit."

Emily McCormack, director of service operations for VGM Insurance Services, shares additional cautions.2 O&P clinics can offer virtual and remote services to their patients that may be reimbursable by Medicare, and VGM's liability coverage applies to those services. There are, however, three key recommendations provider facilities should follow:
  • Treat any telehealth service like you would a direct encounter with a patient. Documentation is as vital in a telehealth episode as it is in an in-person visit.
  • Providers should create a waiver or disclosure and provide it to their patients, clearly specifying services that will or will not be provided via telehealth means. This should be signed by the patient prior to providing service.
  • The waiver should include verbiage that the business is not responsible for bodily injury or damage of any other kind, sustained in connection with their services.

 "Don't stray beyond your scope of practice in a telehealth encounter; stick to those services that you would normally provide to a patient," she adds. "And remember that little things are easily overlooked in a phone call or FaceTime visit—things you'd be less likely to miss during direct patient interaction."

Look before you jump, McCormack advises: Review with payers to be sure that whatever telehealth services you provide to patients will be reimbursable. Confirm that your telehealth service is protected by "very, very strong, robust cybersecurity measures—firewall protection, everything." Be aware that even if your measures are bulletproof, your patient's system may not be fully armored.

"If there is a breach, and someone has hacked into the patient's files or the call or virtual event, the provider could be the one held responsible—even if the breach is due to a lack of security on the patient's side," McCormack warns. "The first step in protection is not just having insurance; it's making sure you have the security measures and risk mitigation in place to prevent that breach from ever happening."

Telehealth Possibilities Are Limitless

Current telehealth systems have limitations for O&P, due to a necessary reliance on hand skills, agrees Jeff Erenstone, CPO, Mountain O&P Services, Lake Placid, New York.

"Mountain Orthotics and Prosthetics has had a satellite branch for the last 12 years," he says, "so it's just sort of been a steady increase in remote capability. The big game-changer was to have web-based CAD software. Then I could access it anywhere in the world."

Operation Namaste, Erenstone's nonprofit, is dedicated to building a collaborative care O&P platform that enables the virtual communication of the needed hand skills to those serving patients on the other side of the planet. There is a shortage of O&P providers in developing countries, where only an estimated 5-15 percent of those who could benefit from prostheses and orthoses are able to access them, which highlights the impact telehealth capabilities could make to the underserved.

While current telehealth networks are still missing this vital element, future software—now in the alpha stage of design and testing—may provide it.

"Though there's not a good virtual reality system with haptic feedback—yet," Erenstone says, "the gaming industry has created really good software that still isn't clinically relevant. But the libraries and the nuts and bolts are all out there for us to kind of put it together in a different software package that's designed for clinicians."

Touch screens are a familiar first step toward the kind of kinesthetic communication necessary to convey the experience of touch through technology that applies forces, vibrations, or motions to the user.

"The real value that Operation Namaste aims to provide," he points out, "is the ability to get a practitioner in Nepal to work with a practitioner in Canada, sharing expertise through real-time dialogue while the two examine and discuss the same scan—applying different skills and styles to interpret and resolve the patient's issue.

"That same type of dialogue is valuable across the world or across town, especially if you can't get across town because you're socially distanced. It just helps everyone stay on the same page," he says.

Frank Snell, president, Snell Prosthetics & Orthotics, Little Rock, Arkansas, equipped his practice several years ago with a PC-based group videoconferencing system. At the time, his objective was to promote administrative communication between satellite offices.

In combination with OPIE Software, the VTel system quickly became a valuable tool for managing the workload throughout the offices. But it also facilitated interoffice collaborative care for patients, as practitioners shared insights and opinions during real-time teleconsultations, improving patient outcomes.

COVID-19 has reduced the number of patients who choose to travel to the main office from outlying areas, Snell observes. As they instead seek out the nearest Snell satellite, their transition to a local practitioner is eased by video introductions and knowledge hand-offs.

He cites a case where, during the COVID-19 shutdown of an amputee clinic, physicians have been able to connect via VTel while a patient visits with the prosthetist, enabling the physician to then review the necessary reports and provide approval and appropriate HIPAA-compliant documentation. "It hasn't been frequent, but it certainly has been valuable," he notes.

"It would be beneficial to be able to check in with patients who report issues, document those issues, and offer advice or recommend an office visit. This aspect of telehealth is something I'd like to see more and more developed."

What's Legal?

Stephen B. Fletcher, CPO/L, director, clinical resources, ABC, shared some observations:

"One of the potential challenges with telehealth is making sure documentation requirements are met. Since the patient is not coming to your office, it can be a challenge to ensure you have a complete chart, like having them sign warranty information and HIPAA charts, etc. If you haven't invested in the appropriate telehealth technology, it can be difficult to accomplish simple things, like how to get a delivery receipt signed."

Implementation of the patient's treatment plan is one of the domains of practice identified in the ABC Orthotic, Prosthetic, and Pedorthic Scope of Practice. Assuring that the device fits properly—which Fletcher notes cannot really be done virtually—is implicit in that implementation. "How would you document that you've assured that the device was fitting and functioning appropriately through a virtual visit? I don't have an answer. That's one of the challenges," he says.

Another potential hurdle Fletcher cited is that providing a prefabricated orthosis based on measurements taken by the patient during the course of a virtual visit can create problems. If the device doesn't fit, it's the provider's responsibility, even if the patient-provided measurements were incorrect. Thus, does the provider potentially create ill will by charging a return or restocking fee, or live with the loss?

Early anecdotal stories from O&P practices lead Fletcher to believe that most are more interested in using telehealth as a stop-gap response to COVID-related restrictions, rather than trying to implement it as a viable way of delivering care. But he agrees that current usage and familiarity will encourage the profession to evolve toward increased use of telehealth—perhaps beginning with follow-up appointments that spare mobility-challenged patients the hardship of travelling, while still maintaining their important personal connection with a trusted provider.

"Telehealth is proving itself as a viable way of delivering care to improve access for patients without needing to travel to a facility, so I think it will definitely grow," he concludes. "Just be sure your telehealth system is HIPAA compliant, and, since every state has its own regulations, learn how their privacy and confidentiality requirements impact your usage. Providers need to be thoughtful before jumping in too quickly," he advises.

Ashlie White, director of strategic alliances, American Orthotic and Prosthetic Association (AOPA), agrees, and notes that AOPA member benefits include access to the AOPA Co-OP, an online reimbursement, coding, and policy resource that includes references to each state's specific restrictions and requirements relative to delivery of care.

She notes that on behalf of providers, AOPA has been seeking guidance from CMS in three areas:

  • Therapeutic shoes.  
    AOPA staff recently participated in educational webinars presented by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and on DME MAC provider advisory councils during which they confirmed that physicians, including medical doctors and doctors of osteopathy that are certifying the medical need for diabetic shoes may utilize telehealth to fulfill face-to-face encounter requirements during the COVID-19 public health emergency.
  • Telehealth documentation.
    Will documentation created during a telehealth visit with a physician be considered valid beyond the period of this temporary CMS waiver, for purposes of delivery and reimbursement at a later time?"We have requested guidance from the DME MACs regarding the legal validity of those patient records created by a physician in a virtual or telehealth environment to serve for establishing medical necessity for delivery in the future," White explains.
  • Reimbursement for O&P telehealth.
    AOPA is working with O&P Alliance partners to explore provider reimbursements for telehealth services that are provided outside of the 90-day framework currently reimbursed under the Healthcare Common Procedure Coding System coding system. "O&P patients still need assessments, device troubleshooting, education, and follow up right now," White stresses. "O&P patients can usually walk into an office if they have an issue, but in the current environment they may be unable to do so."

This effort to gain recognition and reimbursement for clinicians' services—at a time when, like doctors, nurses, and first responders, they are working at risk, in frontline conditions to serve patients during a pandemic crisis—is part of a long-term strategy to later address another AOPA goal: "Clinicians should be reimbursed for their services which were not associated with the delivery of a device," White says. However, she is reluctant to jeopardize chances for long-term success by connecting this separate initiative with efforts to address the immediate need during the COVID-19 crisis.

While telehealth in O&P has its limitations, it's clear that the profession is exploring its potential as well. And during the COVID-19 pandemic, the profession continues to embrace creativity in search of ways to meet patient needs while allowing them to stay safe at home.

 

Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.

Medicare's definition of telehealth: "Medicare telehealth services include office visits…consultations, and certain other medical or health services that are provided by an eligible provider who isn't at your location using an interactive 2-way telecommunications system (like real-time audio and video)."
(www.medicare.gov/coverage/telehealth)

 

References

1. ABC's Statement on Telehealth in O&P. https://bit.ly/2TrxJoq

2. See more at "The Hidden Risks of Telemedicine"
Posted On: July 15, 2019 by VGM Insurance https://www.vgminsurance.com/blog/post/the-hidden-risks-of-telemedicine