As some doctors' offices in Michigan have been shuttered during the coronavirus pandemic, the Clarkston Medical Group in Oakland County has continued to treat patients — providing virtual office visits to about 1,000 per week during the public health crisis. 

The Clarkston Medical Group, which has about 35,000 active patients, started using telemedicine on a limited basis in 2018 through eVisit, a virtual office visit platform that can be accessed from an iPhone or personal computer. Patients check in, provide billing information and medical history, and then meet with a doctor through a video link. 

"It used to be we were doing 250 to 350 (eVisits) a month," and in a recent week alone did 1,000 eVisits, said Dr. Renny Abraham, managing partner of the Clarkston Medical Group. "We've changed everything as much as we can to do eVisits.

"It isn’t a complete physical, but we can go over labs, we do medication refills, we try to keep seniors at home. ... It’s amazing how many people are able to use the platform."

The use of telemedicine — treating patients remotely by phone or computer — has advanced by decades in a matter of weeks, experts said. Hospitals and doctors are moving quickly to adopt the technology after regulatory obstacles were removed by government agencies and lawmakers starting in early March.  

The technology for telemedicine is spreading quickly during Gov. Gretchen Whitmer's stay-home, stay-safe executive order, according to the Michigan Health Information Network, a public, private and non-profit  hub for the secure exchange of medical information between health care providers across the state. The network has been equipping medical practices with a virtual care platform called CareConvene.

"The numbers are going up each day, they're doubling almost daily," said Tim Pletcher, executive director of the Michigan network, about the medical practices that requested the CareConvene technology, adding that about 600 providers were connected a few weeks ago. "We expect it to be in thousands" by the end of this week.

Michigan's largest insurer is spurring the process along. Blue Cross Blue Shield of Michigan and Blue Care Network is providing no-cost telehealth services to members with existing telehealth benefits nationally through at least June 30, including common behavioral health therapy, and most common office visits and hospitalization follow-ups.

"We know that people may have trouble getting into their doctors offices right now," said Janet Fava, vice president of market solutions development and delivery for the Blues. "We’re looking at safety of patients, that is No. 1. That’s our primary concern."

Bret Larsen, president, CEO and founder of eVisit, said the Phoenix-based company has been flooded with new business from health care providers in recent weeks.

“Around this COVID scare, we have oncologists who are reaching out and looking to how to keep cancer patients out of the exam rooms,” Larsen said. “We have obstetricians who are looking to keep their patients (who need) check-ins out of exam rooms. We have hospitals who are trying to keep at-risk providers from being exposed, but still trying to keep them actively engaged in patient care.”

How it works

The Clarkston group's office is still open for essential visits, though patients are assessed for COVID-19 at the door, and their temperatures are checked.

One recent patient was treated for a broken arm. Another received emergency surgery for a perforated bowel in one of the office's operating rooms. Neither went to a hospital because emergency rooms are overrun by COVID-19 patients, Abraham said.  

The Clarkston Medical Group has set up a mobile clinic behind the office for patients who are sick. There is drive-up lane for COVID-19 testing, but patients are assessed in advance during an eVisit.

The combination of telemedicine and limited office visits has allowed patients to continue to receive care, while protecting doctors and other stall from exposure to the deadly coronavirus, Abraham said. 

"Our office is fever-free, sickness-free," he said. "And the sick people we have to see, we see in their cars in the parking lot."

While commercial telemedicine companies offer similar platforms, they're not necessarily connected with the state health department, hospitals and others that are part of the network, Pletcher said.

The Michigan Health Information Network was created in 2010 by the state Health Information Technology Commission to connect health care providers to share electronic medical records, but has gone beyond that mission to meet the growing demands for connectivity.

"What we're trying to do now is provide a level of coordination so that the telehealth providers share information with the state and with everybody else," Pletcher said. 

The goal is to protect Michigan's medical workforce at a time when they're critically needed during the pandemic. 

"We're trying to provide access for people so they don't have to go interact with other places and risk unnecessary exposure," Pletcher said. "We will other work with other folks who are doing telehealth so we can move their data around, or we offer a tool for telehealth."

Crisis loosens rules

Health policy experts for decades have urged the increased adoption of telemedicine to improve efficiency and reduce health care costs in America's health care system.

But progress was slowed by the inability of health care providers to seek reimbursement for telemedicine services, as well as concerns about privacy laws and other regulatory obstacles. 

As the pandemic unfolded across the country in February and March, federal and state agencies, lawmakers and health insurers began to unravel the restraints. The Medicare program started, and other payers followed suit. 

The federal Centers for Medicare and Medicaid Services, starting in early March, issued a series of waivers to roll back restrictions that limited payments for telemedicine services by Medicare, the federal health insurance program for older and disabled Americans.

Previously there were scores of requirements about who could originate the call to the location they called from or the technology and equipment they used, said Laura Appel, senior vice president and chief innovation officer with the Michigan Health and Hospital Association.

"Now, if you are able to do it, Medicare wants you to do it, and they will figure out a way to pay for it," Appel said.  "And this is true about short visits, long visits, through patient portals, you name it."

The Michigan Department of Health and Human Services has requested two federal waivers to expand access to telemedicine for people enrolled in Medicaid or the Healthy Michigan plan, the state's expanded Medicaid program. More than 2.5 million Michigan residents are covered by the federal health insurance program for low-income people, which is funded by both the federal government and the state. 

The waivers, which include changes to make it easier for people to enroll in Healthy Michigan and obtain medical treatment, have already been implemented in the state, said Laura Kilfoyle, a policy specialist with the Health and Human Services Department.  

One of the waivers allows beneficiaries and their health care providers, including mental health therapists, to conduct telemedicine visits from their homes. Previously, both parties had to be at an approved site such as a clinic, Kilfoyle said.  

The other waiver allows health care providers to bill for visits that are made by phone without an audio-visual component. The previous requirement for face-to-face engagement was an obstacle for patients who lacked access to Face Time, Skype or similar technology, she said. 

"This obviously will expand access to people who don't have smart phones or who live in areas that don't have broadband," Kilfoyle said. 

"We're hoping that a lot of providers will be able to provide service from their home," she added. "We're trying to increase the amount of discretion that our providers have, and give them flexibility during this time.

"We really want people to be able to access their providers that they've been seeing for a long time, and we hope that by taking down some of these barriers that they'll be able to do that."

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