Discussion: Telehealth legislation

Education and Practice Primary-care registered nurse telehealth policy implications Susan Watkins Journal of Telemedicine and Telecare 0(0) 1–4 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1357633X20940142 journals.sagepub.com/home/jtt and Judy Neubrander Abstract Coronavirus disease 2019 (COVID-19) has drastically changed health-care delivery models within primary-care settings. Primary-care providers are limiting routine care face-to-face office visits while triaging COVID-19 symptomatic patients to hospital emergency rooms. Primary-care providers are rapidly adopting telehealth modalities for care provisions during this unprecedented pandemic to allow practices to continue delivering primary care while preventing community spread of COVID-19. Federal legislation has responded to emergent public-health needs by removing barriers that have impeded widespread adoption of telehealth modalities. This legislation has omitted professional registered nurses (RNs) from delivering reimbursable telehealth services, which is problematic for primary-care practice. RNs historically have led telehealth service delivery and should therefore be included in new legislation as eligible health professionals permitted to provide reimbursable telehealth services. RNs improve quality outcomes in primary care within innovative team-based care models and are essential clinicians capable of providing ongoing care coordination and disease management for patients needing to stay on track with their usual care needs. Keywords Telecare, telehealth, telemedicine, telenursing Date received: 8 April 2020; Date accepted: 11 June 2020 Accelerated Virtual Care Demand The coronavirus disease 2019 (COVID-19) pandemic has accelerated the demand for health-care delivery systems to enhance virtual care accessibility modalities that promote cost-effective, high-quality and personcentred care. The COVID-19 public-health recommendations to minimize community viral spread are consequently devastating the financial viability of non-essential businesses, along with essential community-based health-care entities.1 Primary-care practices, although essential, have been required to reserve face-to-face visits for emergent care needs, along with encouraging patients with symptoms consistent with COVID-19 to stay at home or seek emergency room care.1 The COVID-19 pandemic has resulted in primary-care practices experiencing significant staffing furloughs, reduced visit capacity and decreased revenue from face-to-face visits.1 Moreover, since many primary-care practices still operate within feefor-service reimbursement models that reward practitioners based on face-to-face office visit volumes to generate revenue, primary-care providers (PCP) are concerned about the financial viability of their practice during this unpredictable pandemic.1 Telehealth modalities for delivering virtual health visits have attracted significant attention by primary-care practices during this unprecedented pandemic, although telehealth has been an approved and reimbursable service through the Center for Medicare and Medicaid Service (CMS) since 1997.2 Prior to the COVID-19 pandemic, less than 10% of PCPs had adopted telehealth technology to conduct virtual visits for reasons including complicated technology, patient confidentiality and reimbursement obstacles.3 As a result of the COVID-19 pandemic, CMS has expanded telehealth reimbursement through the Coronavirus Aid, Relief, and Economic Security (CARES) Act as an emergent response to the healthcare market’s access and financial sustainability Mennonite College of Nursing at Illinois State University, USA Corresponding author: Susan Watkins, Mennonite College of Nursing at Illinois State University, 203 Edwards Hall Campus Box 5810, Normal, IL 61790, USA. Email: smwatk2@ilstu.edu 2 concerns.4 Along with the CARES Act, the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019 (CONNECT Act) will be proposed in 2021 in order to reduce Medicare telehealth obstacles within the Social Security Act.5 The CONNECT Act could also renounce complicating telehealth live-video, asynchronous store-and-forward, and originating patient/provider site and service modality requirement obstacles that have hindered widespread adoption of telehealth services in primary care.5 These legislation efforts are significant benefactors to increasing widespread adoption of telehealth within primary-care practices to allow providers the capability of providing essential healthcare services for acute illness and chronic disease management.1 However, registered professional nurses were omitted as eligible providers of reimbursable telehealth services within both of these Acts.4,5 This is a significant oversight, as CMS has permitted other non-faceto-face registered nurse (RN) services to be billed and reimbursed under the supervising PCP to support chronic care management (CCM) and transitional care management (TCM).4 These approved nonface-to-face RN remote care services were influential to the US health-care system considering that CMS approval for reimbursement often signifies an intervention’s potential for widespread utilization.6 TCM services were originated in 2013 by CMS to support beneficiaries transitioning from a hospital or skilled nursing facility (SNF) to a community setting during the first 30 days after discharge.4 TCM was the first service that could be ordered by the PCP and supported by auxiliary personnel, such as RNs who provide the services directly face-to-face or nonface-to-face as a therapeutic care coordination service under the ‘incident to’ benefit with PCP supervision.4 CCM services were originated by CMS in 2015 to qualifying beneficiaries having a minimum of two chronic diseases that increase risk of exacerbation and mortality and who are established with a supervising PCP and a comprehensive care plan.4 The original CCM service in 2015 included up to 20 minutes per month of care coordination and disease self-management support provided by a RN directly supervised by the PCP.4 In 2017, CMS increased payment under CCM for complex service delivery for consenting beneficiaries, which includes moderate to high-complexity medical decision making, and 60 minutes additional clinical staff time each month supervised by the PCP for disease selfmanagement support.4 These complex CCM services can be delivered by the RN as face-to-face or nonface-to-face for consenting beneficiaries under the orders and supervision of the PCP to assist patients with care coordination and disease management.4 Journal of Telemedicine and Telecare 0(0) The CMS TCM and CCM provisions had a significant impact on widespread adoption for RNs supporting non face-to-face reimbursable telehealth nursing services.6 CMS TCM and CCM provisions will need to be expanded within state policies to increase national implementation of telehealth platforms.2 Telehealth nursing services have become an essential team-based primary-care chronic disease management and care coordination commodity that supports population health improvement efforts in the USA.6 Evidence suggests telenursing services provide patients with additional accessibility and support for disease symptom monitoring and disease self-care guidance.7

Evidence also supports a positive link between telenursing and improved diabetes glycaemic control.8 International evidence further supports telenursing as a safe, effective and high-quality remote access service for health care.9–11 Telehealth nursing practice leverages technologybased communication platforms to provide distant nursing services to patients,12,13 including consultation, assessment, monitoring, treatment and patient education.14,15 Telehealth nursing accessibility reduces travel requirements, unnecessary provider visits and emergency room unitisation while maintaining quality and efficiency16,17 associated with improved patient outcomes and reduced health-care costs.2,18 Neither the CARES or CONNECT Act legislation contain professional RNs as an eligible provider of telehealth services.5 Instead, the proposed eligible health professionals within these Acts are: ‘physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, and registered dietitian or nutrition professional’.5 Professional RNs are key inter-professional team members within teambased primary-care models to support complex chronic disease management and care coordination efforts.19 RNs supply the largest health-care occupation20 and are well positioned to assume more telehealth roles while increasing revenue within pandemic-besieged primary care settings. The literature demonstrates that RNs in team-based primary care partnerships are well prepared to care for patients with chronic illness such as congestive heart failure, diabetes and hypertension utilizing telehealth modalities.21 Telehealth nursing scopes and standards were first published in 2011 for ambulatory care RNs who provide evidence-based telehealth services in accordance to American Academy of Ambulatory Care Nursing guidelines.22 RNs have been utilizing e-visit tools, electronic health record portal platforms and digital mobile remote monitoring technology within ambulatory care settings to provide asynchronous chronic disease guidance, care plan evaluation and disease self-management Watkins and Neubrander through enriched communication modalities to support patients as active participants in their care between provider visits.21,22 RNs also provide expert telehealth services for triaging patients to the appropriate level of care, utilising clinical judgement, algorithms and evidence-based guidelines.22 The high-level RN knowledge and skills of assessment paired with clinical decision expertise allow the RN to prioritise urgent care needs, develop a plan of care in collaboration with the multidisciplinary care team and provide supportive patient education for treatment recommendations and evaluation of care outcomes.22 RN telehealth supports population health, care coordination, transitional care, disease selfmanagement support, wellness, symptom triage and palliative care for patients and families.22 Modern advancements in RN telehealth services using mobile devices and digital technologies are consistent with the CMS definition of ‘telemedicine’. CMS defines ‘telemedicine’ as utilizing virtual visit modalities to connect with health professionals ‘to exchange health care information in audio, video, graphic, or other format for the purpose of providing improved health care services’.23 RN-led telemedicine interventions have been linked to improved disease self-management behaviors associated with reduced HbA1C levels and decreased blood pressure levels.24 The omission of RNs as eligible telemedicine health professionals will intensify the unprecedented challenges primary-care providers are facing related to the COVID-19 pandemic. It is essential for legislators to recognize the urgent need for RNs to qualify as one of the additional health professionals to provide reimbursable telehealth services to mitigate pandemicassociated health-care workforce shortages, accessibility to care and declining revenues associated with viral public-health infection control. RNs are well positioned with the knowledge and skills to assist primary-care providers to continue serving the vulnerable patient populations who require high-quality coordinated and ongoing chronic disease self-management and transitional care services across the continuum of care within patient-centred medical home models.24 Declaration of conflicting interests The author(s) declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This project was supported by the Health Resources and Service Administration (HRSA) of the U.S. Department 3 of Health and Human Services (HHS) as part of an award totaling $2.729705m with 0% financed by non-governmental sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the US government. ORCID iD Susan Watkins https://orcid.org/0000-0003-3119-8948 References 1.

Primary Care Collaborative. Primary care and COVID19: week 2 survey, https://www.pcpcc.org/2020/03/26/pri mary-care-covid-19-week-2-survey (2020, accessed 30 March 2020). 2. Neufeld JD, Doarn CR and Aly R. State policies influence Medicare telemedicine utilization. Telemed J E Health 2016; 22: 70–74. 3. Peabody MR, Dai M, Turner K, et al. Prevalence and factors associated with family physicians providing E-visits. J Am Board Fam Med 2019; 32: 868–875. 4. Centers for Medicare & Medicaid Services. Chronic Care Management Services, https://www.cms.gov/outreachand-education/medicare-learning-network-mln/mlnprod ucts/downloads/chroniccaremanagement.pdf (2018, accessed 5 May 2020). 5. Dizon R. Federal CONNECT Act seeks to expand access to telehealth in Medicare. https://www.telehealthresource center.org/federal-connect-act-seeks-to-expand-accessto-telehealth-in-medicare/ (2020, accessed 2 April 2020). 6. Lister M, Vaughn J, Brennan-Cook J, et al. Telehealth and telenursing using simulation for pre-licensure USA students. Nurse Educ Pract 2018; 29: 59–63. 7. Gidora H, Borycki EM and Kushniruk AW. Effects of telenursing triage and advice on healthcare costs and resource use. Stud Health Technol Inform 2019; 257: 133–139. 8. Yang S, Jiang Q and Li H. The role of telenursing in the management of diabetes: a systematic review and metaanalysis. Public Health Nurs 2019; 36: 575–586. 9. Bikmoradi A, Masmouei B, Ghomeisi M, et al. Impact of tele-nursing on adherence to treatment plan in discharged patients after coronary artery bypass graft surgery: a quasi-experimental study in Iran. Int J Med Inform 2016; 86: 43–48. 10. Goudarzian M, Fallahi-Khoshknab M, Dalvandi A, et al. Effect of telenursing on levels of depression and anxiety in caregivers of patients with stroke: a randomized clinical trial. Iran J Nurs Midwifery Res 2018; 23: 248–252. Discussion: Telehealth legislation

11. Graversen DS, Christensen MB, Pedersen AF, et al. Safety, efficiency and health-related quality of telephone triage conducted by general practitioners, nurses, or physicians in out-of-hours primary care: a quasiexperimental study using the Assessment of Quality in Telephone Triage (AQTT) to assess audio-recorded telephone calls. BMC Fam Pract 2020; 21: 84. 4 12. Allen M, Aylott M, Loyola M, et al. Nurses: extending care through telehealth. Stud Health Technol Inform 2015; 208: 35–39. 13. Kumar S and Snooks H. Telenursing. London: Springer, 2011, p.200. 14. Reierson IÅ, Solli H and Bjørk IT. Nursing students’ perspectives on telenursing in patient care after simulation. Clin Simul Nurs 2015; 11: 244–250. 15. Sevean P, Dampier S, Spadoni M, et al. Bridging the distance: educating nurses for telehealth practice. J Contin Educ Nurs 2008; 39: 413–418. 16. Lustig TA. The role of telehealth in an evolving health care environment: workshop summary. Washington, DC: National Academies Press, 2012, pp.1–26. 17. Moehr JR, Schaafsma J, Anglin C, et al. Success factors for telehealth– a case study. Int J Med Inform 2006; 75: 755–763. 18. Edirippulige S. Readiness of nurses for practicing telehealth. Stud Health Technol Inform 2010; 161: 49–56. 19. United States of Representatives. Office of Law Revision Counsel United States Code 42 Section 1115A(b)(2)(B) of the Social Security Act 42 U.S.C. 1315a(b)(2)(B), https:// uscode.house.gov/view.xhtml?req=telehealth+service s&f=treesort&fq=true&num=17&hl=true&edition= prelim&granuleId=USC-prelim-title42-section254c-14 Journal of Telemedicine and Telecare 0(0) 20. 21. 22. 23. 24. https://uscode.house.gov/browse.xhtml (2020, accessed 8 March 2020). Health Resources and Services Administration. Discussion: Telehealth legislation

The future of the nursing workforce: national- and statelevel projections, 2012–2025, http://bhpr.hrsa.gov/health workforce/supplydemand/nursing/workforceprojections/ nursingprojections.pdf (2014, accessed 20 March 2020). American Academy of Ambulatory Care Nursing. Position paper: the role of the registered nurse in ambulatory care, https://www.aaacn.org/sites/default/files/ documents/PositionPaper.pdf (2017, accessed 2 February 2020). Discussion: Telehealth legislation

American Academy of Ambulatory Care Nursing. Telehealth nursing practice, https://www.aaacn.org/prac tice-resources/telehealth (2020, accessed 1 January 2020). Centers for Medicare & Medicaid Services. Trump administration provides financial relief for Medicare providers, https://www.cms.gov/newsroom/press-releases/ trump-administration-provides-financial-relief-medicareproviders (2018, accessed 5 May 2020). Massimi A, De Vito C, Brufola I, et al. Are communitybased nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis. PLoS One 2017; 12: 1–22. Morbidity and Mortality Weekly Report Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020 Lisa M. Koonin, DrPH1; Brooke Hoots, PhD1; Clarisse A. Tsang, MPH1; Zanie Leroy, MD1; Kevin Farris, MAEd1; Brandon Jolly, MD2, Peter Antall, MD3; Bridget McCabe, MD4; Cynthia B.R. Zelis, MD5; Ian Tong, MD6; Aaron M. Harris, MD1 In February 2020, CDC issued guidance advising persons and health care providers in areas affected by the coronavirus disease 2019 (COVID-19) pandemic to adopt social distancing practices, specifically recommending that health care facilities and providers offer clinical services through virtual means such as telehealth.* Telehealth is the use of two-way telecommunications technologies to provide clinical health care through a variety of remote methods.† To examine changes in the frequency of use of telehealth services during the early pandemic period, CDC analyzed deidentified encounter (i.e., visit) data from four of the largest U.S. telehealth providers that offer services in all states.§ Trends in telehealth encounters during January–March 2020 (surveillance weeks 1–13) were compared with encounters occurring during the same weeks in 2019. Discussion: Telehealth legislation

During the first quarter of 2020, the number of telehealth visits increased by 50%, compared with the same period in 2019, with a 154% increase in visits noted in surveillance week 13 in 2020, compared with the same period in 2019. During January–March 2020, most encounters were from patients seeking care for conditions other than COVID-19. However, the proportion of COVID-19–related encounters significantly increased (from 5.5% to 16.2%; p<0.05) during the last 3 weeks of March 2020 (surveillance weeks 11–13). This marked shift in practice patterns has implications for immediate response efforts and longer-term population health. Discussion: Telehealth legislation

Continuing telehealth policy changes and regulatory waivers might provide increased access to acute, chronic, primary, and specialty care during and after the pandemic. Data for this analysis were provided to CDC from four large national telehealth providers as part of partner engagement to monitor and improve outcomes during the COVID-19 pandemic. Datasets included the date of the telehealth encounter, patient sex, age, county and state of residence, and, for 2020 visits, disposition after the visit (e.g., home or location the provider recommended that the patient seek additional care, if needed, such as in an emergency department [ED] or with a primary care provider), “reason for visit” (text field), and diagnosis defined by one or more Internationa …Discussion: Telehealth legislation