Abbreviations
CDC
Centers for Disease Control and Prevention
CMS
Centers for Medicare and Medicaid Services
COVID‐19
coronavirus disease 2019
HIPAA
Health Insurance Portability and Accountability Act
PPE
personal protective equipment
Telemedicine has always had the potential to improve access and reduce the costs of
health care. Because of the coronavirus disease 2019 (COVID‐19) pandemic, telemedicine
has now become a critical way to deliver clinical care.
1
Early in the pandemic, the Centers for Disease Control and Prevention (CDC) recommended
that ambulatory facilities delay elective visits to mitigate SARS‐CoV‐2 transmission
among patients and health care workers.
2
Hospitals and health systems across the United States appropriately canceled nonurgent
clinic visits and procedures, which led to a sudden and urgent need to shift to alternative
health care delivery models for triage, assessment, and patient care.
2
Telemedicine, which includes office visits and other medical services provided at
a distance using interactive two‐way telecommunications systems (i.e., real‐time audio
and video),
3
has the potential to limit the exposure of patients and health care workers to the
clinic environment, help preserve the limited supply of personal protective equipment
(PPE), and reduce the backlog of deferred patient care resulting from the COVID‐19
pandemic response. In turn, this may mitigate the risks for decompensation, morbidity,
and loss to follow‐up that could result from delayed care for patients with liver
disease.
4
A few prescient hospital systems had already implemented telemedicine programs prior
to the pandemic, but the vast majority had not, due in large part to federal and state
regulatory and reimbursement limitations.
There are many reasons why telemedicine had not gained a foothold in the United States
prior to the COVID‐19 pandemic. The Centers for Medicare and Medicaid Services (CMS)
places substantial barriers to the use of telemedicine by restricting it to patients
who reside in rural areas and who must travel to a local medical facility (e.g., doctor’s
office, hospital, dialysis facility, or skilled nursing facility) to receive telemedicine
services from a doctor in a remote location.
3
Most private payers cover some telemedicine services, and many states have enacted
parity laws that require private payers to reimburse the same amount for telemedicine
services as analogous in‐person services. In many cases, however, reimbursement for
telemedicine services is lower than in‐person services. In addition to the regulatory
and reimbursement issues, implementation of telemedicine is limited by technology
requirements, such as Health Insurance Portability and Accountability Act (HIPAA)‐compliant
audiovisual equipment. As a result, telemedicine adoption has been slow.
US lawmakers recognized the critical need to remove barriers to telemedicine care
during the COVID‐19 crisis. The Coronavirus Preparedness and Response Supplemental
Appropriations Act (H.R. 6074) was signed into law on March 6, 2020, and provides
a temporary waiver of many of the CMS restrictions and requirements regarding telemedicine
services during the COVID‐19 public health emergency.
5
Specifically, the bill waives the rural area requirement and the originating site
restrictions, allowing the patient to be located anywhere, including their home, and
telemedicine services will be paid at the same amount as in‐person services. On March
17, 2020, the Health and Human Services Office of Civil Rights announced that it would
not impose penalties for the good faith provision of telemedicine during the COVID‐19
public health emergency, even if the technologies used may not fully comply with HIPAA
requirements.
6
Recently, on April 30, 2020, the CMS announced it would temporarily increase payments
for telephone visits to match in‐person and video visits.
7
Barriers to interstate licensure have largely been lifted. Most states have temporarily
waived interstate licensure requirements, whereas others have enabled rapid provision
of medical licensure during the current public health emergency.
When these barriers to telemedicine were removed, providers, hospitals, and health
systems rapidly embraced telemedicine or scaled up existing programs to meet the sudden
demand for remote, synchronous patient care. As a result, there has been a sudden
and substantial increase in telemedicine visits for urgent and nonurgent ambulatory
care both related and unrelated to COVID‐19, and patient satisfaction for telemedicine
care has been consistently high.
8
The CDC identifies patients with liver disease and immunosuppressed patients to be
at higher risk for severe COVID‐19.
9
It is therefore imperative that we minimize exposure of patients with liver disease
and liver transplant recipients to the health care environment. “Telehepatology,”
or telemedicine for advanced liver disease, has the potential to facilitate care of
this vulnerable population during this critical time.
10
Despite its promise, telehepatology is not a panacea. Some patients with new physical
symptoms or recent hepatic decompensation are best evaluated in person but may avoid
seeking medical care due to social distancing policies or concerns about exposure
to COVID‐19 in the health care setting. Patients in need of liver transplantation
may be challenging to evaluate because of the need for physical examination, frailty
assessment, building rapport, and observing interactions among family members and
other caregivers. It is difficult to initiate a potentially lifelong provider‐patient
relationship via video. In the nontransplant setting, telemedicine may be challenging
for new patients without an established patient‐provider bond or who require discussions
about serious illness or end‐of‐life conversations. More prospective data are needed
in these settings.
In contrast, telehepatology for liver transplant evaluations may present an opportunity
to more efficiently triage patients and expedite the time from referral to evaluation
and listing.
11
It can more readily identify patients with psychosocial or other barriers to transplantation
and prevent futile evaluations
12
(Table 1). The innovative use of telehepatology could allow some transplant evaluations
to occur on‐site while limiting the proximity of physicians and other team members
to patients, a concept coined by our emergency medicine colleagues as “electronic
PPE.”
13
For established patients without fibrosis, with stable chronic liver disease (e.g.,
viral hepatitis, metabolic‐associated fatty liver disease), or with benign liver lesions,
for example, telemedicine can add convenience and efficiency. For established patients
with decompensated liver disease, telemedicine can offer rapid evaluation and avoid
the need for an in‐person appointment when, for example, adjusting diuretics or medications
for hepatic encephalopathy. Caregivers may also be more readily available to join
telemedicine visits rather than take time away from work and other duties. An example
of telehepatology workflow is illustrated in Fig. 1.
Table 1
Pros and Cons of Telehepatology for Liver Transplant Evaluation
Pros
Cons
Limit exposure of patients and health care workers to SARS‐CoV‐2
Preserve PPE
Efficiently triage patients in need of urgent in‐person evaluation
Expedite time from referral to evaluation and listing
Identify barriers to transplantation and avoid futile evaluations
Difficult to build rapport and initiate a potentially lifelong provider‐patient relationship
Limited physical examination (e.g., signs of decompensation, assessment of frailty)
Difficult to observe interactions among family members and other caregivers
Not suitable for all patients (e.g., very ill, difficulty with the technology or technology
not available)
Uncertain feasibility/sustainability following COVID‐19 public health emergency
John Wiley & Sons, Ltd
This article is being made freely available through PubMed Central as part of the
COVID-19 public health emergency response. It can be used for unrestricted research
re-use and analysis in any form or by any means with acknowledgement of the original
source, for the duration of the public health emergency.
Fig 1
Example of telehepatology workflow. Courtesy Thelmelis Abreu.
As incident cases of COVID‐19 decrease, we will need to adopt a gradual, stepwise
approach to the “reentry” process as we start to move clinical activities toward a
prepandemic state. We must continue to limit in‐person patient care where it is appropriate
to avoid a “second wave” of SARS‐CoV‐2 transmission. Even when in‐person clinic visits
and procedures are an option for most patients, many will still prefer telemedicine
alternatives to in‐person care partly out of fear of coming to the clinic or hospital.
4
Patients will largely dictate when they are ready to return to “business as usual,”
and telemedicine will continue to be an important part of getting us there.
As we look to a future beyond the COVID‐19 pandemic, we have an opportunity to consider
telemedicine’s place in the routine delivery of patient care. Telemedicine has the
potential to improve patient care and satisfaction, and improve the way we evaluate
patients for transplantation; it need not only serve its current purpose as a temporary
solution during a crisis. There are many problems other than COVID‐19 that may be
solved by telemedicine, including disparities in quality and access to health care
in both urban and rural areas and the escalating cost of health care.
14
Rather than force most patients and providers into a remote care delivery model, as
we have had to do during the pandemic, we can strategically use telemedicine for both
triage and routine care where it is most appropriate.
Our patients have much to gain from the widespread adoption of telemedicine during
the COVID‐19 pandemic and beyond. Patients are already embracing this mode of care
delivery. For our part as health care professionals, we will need to learn how to
more efficiently integrate telemedicine as one option in our routine care.
14
We will need to learn new skills for conducting telemedicine visits and develop programs
to educate and mentor colleagues and trainees.
8
We need to implement and study care pathways for different patient populations and
determine what is the right patient phenotype and “dose” of telemedicine to optimize
convenience, efficiency, and patient‐centeredness without compromising clinical care.
These answers will undoubtedly vary because of payment strategies, patient preferences,
geography, local resources, and provider acceptance, among other factors. For telemedicine
to remain viable in the future, we need to advocate for legislative reform at the
federal and state levels to preserve many of the current waivers that permit telemedicine
services. These changes will need to be thoughtfully considered and implemented in
a way that is financially sustainable and maximizes patient safety and privacy. There
is reason to hope that this is possible. While the world is ravaged by COVID‐19, perhaps
one desirable lasting effect may be the fulfillment of the promise of telemedicine.