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Arthritis at Work

As we learn new things daily about the coronavirus — and how to stop the spread — it’s no wonder that our heads are swirling with new questions, concerns, and worries every day. For many of our CreakyJoints and GlobalHealthy Living Foundation members, one of those questions is: Is it safe to go to my doctor’s office right now?

The recommendations here have been changing quickly over the past few weeks and will likely continue to change, so we will be updating this resource as needed. You should also note that what’s right for you will depend on your geographic area and how prevalent the community spread of coronavirus is near you.

Our team of patient advocates has been speaking with many different types of health care providers — rheumatologists, dermatologists, cardiologists, gastroenterologists, and others — over the last week and all of them are strongly urging patients to use “telehealth” appointments for routine care instead of seeing the doctor in person.

Some clinics are switching as many patients as possible over to telehealth visits and reserving in-person visits only for very serious issues.

What Is Telehealth?

Telehealth, or telemedicine, means seeing your provider over a video/audio service, like FaceTime, Skype, or a specific app intended for this purpose. It can also include phone calls.

“With telehealth, doctors see patients face to face instead of touch to touch,” says Lynette Byrnes, senior vice president of practice management services at United Rheumatology, a New York-based rheumatology care management organization that serves more than 600 independent rheumatologists across the U.S. “Patients need to stay connected with their physician right now and continue their care. Changes in how doctors are providing telehealth services is allowing this to happen in new ways right now.”

For patients with chronic illnesses — such as inflammatory autoimmune conditions, who are accustomed to seeing a provider every few weeks or months to check on their condition, make medication adjustments, and more — the thought of not having in-person access to your provider can be a little disconcerting. You may be wondering: Will you be able to still get the level of care you need?

We talked to rheumatologist Alvin F. Wells, MD, PhD, director of the Rheumatology and Immunotherapy Center in Franklin, Wisconsin, who has been helping to pioneer telemedicine for rheumatology clinics for years — and has been offering these services to patients prior to the COVID-19 pandemic — about how virtual doctor visits can help to quell fears during the coronavirus pandemic.

The biggest benefit of telehealth, says Dr. Wells, is that you get immediate access to your health care provider without any potential exposure to the virus. “Until we get more widespread testing, we don’t know who might be sitting next to you in the waiting room — or which provider may have been exposed to the virus,” he says.

New Rules on Telehealth

Telemedicine is far from new, but it is becoming more top-of-mind as public health experts continue to look for ways to “flatten the curve” and protect high-risk patients from potential COVID-19 exposure.

Under the President’s emergency declaration, the Centers for Medicare & Medicaid Services (CMS) recently loosened HIPAA health privacy laws for telehealth. This allows health care professionals without HIPAA-approved platforms to use the following apps to diagnose and treat patients:

  • Apple FaceTime
  • Facebook Messenger video chat
  • Google Hangouts video
  • Skype

Doctors may also utilize specific telehealth platforms through their electronic medical record software.

CMS created new billing codes specifically for telehealth appointments, which means doctors can be reimbursed for these visits similarly to how they would get paid for regular in-person appointments. Both of these changes are critical for the fast and widespread adoption of telehealth.

In other words, these new changes have removed a lot of the red tape that used to prevent doctors from being able to easily adopt telehealth and make it part of their practice.

While the current changes only apply to Medicare, typically private insurance companies follow suit and adopt similar policies.

“Temporarily if a doctor wants to chat with you on Facetime or Skype, it is no longer considered a HIPAA violation,” says Lawrence Green, MD, clinical professor of dermatology at George Washington University School of Medicine in Washington, D.C. “[Telehealth] is an excellent way for your doctor to see you, but make sure to do a live interaction, not an email chat.”

Ways to Utilize Telehealth Right Now

Some doctors, such as those in primary care, may be using telehealth to screen patients for coronavirus symptoms and decide whether people need to come in for testing.

And in addition to using telehealth for regular check-ups for managing chronic health conditions, telehealth can also be used for one-off minor health issues to avoid needing to go to the doctor in person — say, for a rash or a GI complaint.

Telehealth services can also provide virtual mental health support for any coronavirus-related depression or anxiety you’re currently experiencing.

Consider some of the many ways you can use telehealth:

  • Video chat about your symptoms or medication side effects
  • Send over a picture of a rash or other symptom of concern
  • Check in to see how you’re managing your inflammatory arthritis, or other chronic health condition
  • Have a therapy session
  • Get a prescription refill
  • Get a referral to another specialist
  • Get a second opinion

How Telehealth Actually Works

Dr. Wells, who is licensed to practice telehealth in Wisconsin, South Dakota, Montana, Illinois, and North Carolina, says he has seen an uptick in telehealth visits during the coronavirus pandemic so far.

“Many patients have called saying things like, ‘I’m on a biologic and have a cough and low-grade fever — and I’m not sure what to do?’” says Dr. Wells. Telehealth visits allow him evaluate patients’ symptoms and determine what to do next — without you having to take multiple trips outside your home. “Fifteen minutes and you hang up the phone. It’s that simple and easy,” he says.

For a routine rheumatology visit, a patient will call Dr. Well’s practice and log in using Zoom (a video-conferencing technology) on their computer or phone. They have a dedicated 30-minute appointment. You are able to see and hear the physician — and the physician can see and hear you.

“We spend the first one or two minutes discussing the patient’s complaints — ‘I have pain and stiffness’ or ‘I can’t sleep at night’ — and then we do a virtual joint exam,” says Dr. Wells.

This includes asking the patient to do the following:

  • Make a fist
  • Motion like you’re writing
  • Make a claw-type gesture
  • Make the prayer sign

Next, Dr. Wells asks whether the patient is experiencing any rashes, mouth sores, or GI issues like nausea or vomiting. The last five minutes is spent summarizing and documenting the information. “You get a dedicated time to address questions and the patient hasn’t left the home; it’s very efficient,” he says.

Naysayers of telehealth often cite the lack of a physical exam as being problematic, but Dr. Wells notes that a virtual visit is not the end of the line.

“You’re still a physician and you’re going to use your medical knowledge. You know what’s routine and expected on the medication versus what’s out-of-the-ordinary and when the patient may have to come into the office,” he explains. “The virtual visit is the trigger. It helps us understand whether a patient may need to get X-rayed or have labs done. Then, we can reconnect tomorrow, and based on the results, determine if you need to come in or if we can prescribe medication over the phone.”

“You don’t necessarily have to touch to treat,” says Byrnes. “It can be a more limited exam, but it’s an important way for the patient and doctor to stay connected, review labs, make sure patients are staying on their therapies, and answer any questions — especially about COVID-19 — that they may have.”

What to Ask Your Doctors About Telehealth Services

If you have an upcoming appointment scheduled with your doctor and they have not yet proactively reached out to you about it, it’s a good idea to call and ask whether the appointment can be conducted as a telehealth visit.

“Each practice will have its process for using telehealth,” says Byrnes. “You need make to sure you understand from them what to expect and how you will log on to speak with the doctor.”

Importantly, says Byrnes, “do not cancel upcoming appointments. Call the office and find out how you can work together to be seen.”

You should ask what to expect in terms of insurance coverage and payment. You will likely still have your usual coinsurance or copay; though it might be less than usual if your appointment is more limited in scope.

You can also contact your insurance carrier to inquire if they offer any telehealth services as well as what is (and what isn’t) covered outside of these services. To help keep at-risk seniors safe during the coronavirus, Medicare (administered by CMS) will allow health providers to waive or reduce cost-sharing for telehealth visits.

There are also several private companies that offer basic telehealth services for primary care through mobile apps, including MDLIVE, Amwell, Doctor on Demand, Talk Space and others. HealthLine has a list of highly rate telemedicine apps, though the Global Healthy Living Foundation has not vetted these and cannot recommend any of them specifically.

Telehealth is a smart way to reduce your exposure to the coronavirus and to stay safe, but take heart. Even if you do have to schedule an in-person visit with your doctor, they are likely taking extra precautions to keep their patients safe. They should be using social distancing recommendations for health care settings.

“We only allow two patients in the waiting room at one time. If there are four, we ask two to wait in their car,” says Dr. Green, who wears a mask and gloves when treating patients and gives the exam room a top-to-bottom cleaning with special antiseptic wipes after each visit.

“We go overboard between patients,” he says. “I want my staff and my patients to stay healthy.”

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ACR Telehealth Provider Fact Sheet. American College of Rheumatology. https://www.rheumatology.org/Portals/0/Files/ACR-Telemedicine-Fact-Sheet-2020.pdf.

Interview with Alvin F. Wells, MD, PhD, rheumatologist and director of the Rheumatology and Immunotherapy Center in Franklin, Wisconsin

Interview with Lawrence Green, MD, clinical professor of dermatology at George Washington University School of Medicine in Washington, D.C

Interview with Lynette Byrnes, senior vice president of practice management services at United Rheumatology

Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. U.S. Department of Health & Human Services. March 23, 2020. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.

Timmons J. The Best Telemedicine Apps of 2019. May 22, 2019. https://www.healthline.com/health/best-telemedicine-iphone-android-apps.