HIV Specialist - March 2021 - 24

Figure 1: Telehealth Considerations

Etiquette

Digital Divide
* Aging population with HIV
* Trust and Privacy Concerns
* Non-English speaking clients

Hidden Costs
* EMR, software and
hardware
* Telemed centers
* Trained telepresenters
* Physician licensing
* Call coverage
* Provider Training

* Who is right for this visit?
* Limited physical exam
* Delay in labs and preventive care

Time Management
* On time patients
* " Rooming " the patient
* Technical difficulties

Reimbursement

Care Delivery

* Different payer rules
* Delayed payments due to
changing processes
* Loss of hospital clinic fee

* Contracts
* Intersection of private entity
and non-profit
* Whose patients?
* Lab access

the power of telehealth to deliver care to our patients?
Our Ryan White clinic is located at the University of
Pittsburgh Medical Center (UPMC) and has been serving
the southwestern region of Pennsylvania including some
clients from West Virginia and Ohio since 1994. We
have approximately 1900 clients with a median age of
52. Three quarter of the clients are male and 45 percent
identify as African-American. Our care delivery model is
comprehensive and in addition to HIV and primary care
includes: behavioral health, nutrition, anal dysplasia, pain
clinic, women's health, pre-exposure prophylaxis (PrEP),
sexually transmitted infection (STI) testing and treatment, pharmacy and case manager support, and clinical
and basic research. Historically, Medicare only covered
very specific telehealth services that were delivered to
patients living in a defined geography, e.g., rural health
provider shortage area (HPSA).
In 2019, Medicare began to cover services such as
brief check-in visits, electronic consults, and remote
monitoring for patients living outside of HPSA. But, this
was challenging to operationalize due to complicated
rules. Thus, our clinic had stuck to a traditional brick and
mortar style of delivering care. However, in early 2019,
our UPMC health plan began to encourage all providers to conduct telemedicine visits which were being
reimbursed at in-person rates. These visits demonstrated
good outcomes and were deployed to include other health
plans. With the system's support behind us, our clinic was
able to implement two different models of telemedicine
several months before the first case of COVID-19.
The first model uses a smartphone device to conduct a Health Insurance Portability and Accountability
Act (HIPAA) compliant audio/video visit between the

Triage

* Staying professional and on task
* Incorporating learners
* Missing the human touch

MARCH 2021 HIVSPECIALIST WWW.AAHIVM.ORG

provider (located in Pittsburgh) and the patient (located
at home). All the documentation and orders are completed
electronically. This model is similar to what most health
systems and clinics have deployed since the start of the
pandemic in order to be able to complete visits safely.
However, given that all our providers were trained on and
already using video visits, it was remarkably easy to switch
to primarily telemedicine when the first confirmed case of
COVID-19 was diagnosed in Allegheny County in March
2020. By then, Medicare had also made several changes to
permit great access to virtual health for patients regardless of geography and modality.
The second model takes the HIV care delivery model
directly to the patient's rural community. Patients living
in rural HPSA face multiple challenges including lack of
access to subspecialty care, transportation issues, and
stigma. The patient is seen at a clinical location which is
a dedicated telemedicine medical practice. The physician
(located in Pittsburgh) uses audio/video interface to conduct the visit, but the patient also has a trained tele-presenter (registered nurse) in the exam room. This model
allows us to conduct a history and a head-to-toe physical
exam with the tele-presenter's assistance and Bluetooth
enabled equipment (i.e. stethoscope, otoscope, ophthalmoscope) via HIPAA compliant software. All the documentation and orders are completed electronically. Although the
patient is never seen in-person in Pittsburgh, they have full
access to the standing clinic and its services.
We currently have two telemedicine clinics in rural
Pennsylvania, and although they temporarily closed at
the onset of the pandemic for the safety of patients and
staff, both reopened quickly. Amongst the nine patients
that have been seen via this model in the past year, six

SHUTTERSTOCK/ ILLIZIUM

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HIV Specialist - March 2021

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