Coronavirus disease 2019 (COVID-19) is a highly contagious disease caused by the severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The COVID-19 pandemic presents
an unprecedented crisis for patients, clinicians, and healthcare systems in the United
States (US). In response, US Federal and State governments have implemented wide-ranging
stay-at-home recommendations as a means to reduce spread, and have ordered non-essential
businesses to temporarily close. At the time of this writing, social distancing is
the only known way to mitigate the continued spread of COVID-19, as there is currently
no proven vaccine or treatment. In an effort to reduce patient exposure and transmission
of disease, to conserve supplies, and to maximize personnel that are needed to provide
care to the large number of severe COVID-19 cases requiring hospitalization, many
US healthcare systems have reduced ambulatory outpatient clinics—pillars of the longitudinal
care of patients with chronic illnesses such as heart failure (HF). In this context,
synchronous audio/video interactions, also known as virtual visits (VVs), have been
suggested as innovative and necessary alternatives to in-person care.
VVs provide a platform for real-time interactive telehealth interactions between patients
and clinicians using commonly-available home-consumer devices. Early adopters of VVs
have described their feasibility, potential to save time and cost, and patient satisfaction
related to increased access to care and the convenience of avoiding a trip to the
office.1-5 The US Department of Veteran's Affairs (VA) has been a leader in the use
of telehealth. In FY 2019, more than 99,000 Veterans used the VA Video Connect app
at their home resulting in 294,000 virtual appointments.6 Although the majority of
these visits were for mental health, the VA experience demonstrates the feasibility
of broadly utilizing VVs to provide care for chronic illness.
The value of VVs was recently demonstrated in a randomized clinical trial evaluating
VVs versus in-person ambulatory visits in the post-discharge care of patients with
HF (Virtual Visits in Heart Failure Care Transitions (VIV-HF); NCT03675828; Late Breaking
Clinical Trial presentation at the Heart Failure of Society of America's Annual Scientific
Meeting 2019 in Philadelphia, PA). The aims of this pilot study were to test the feasibility
and safety of substituting in-person visits with VVs for patients (n=108) transitioning
from hospital-to-home after hospitalization for HF, and to assess to what degree VVs
can reduce appointment no-show rates. The no-show rate in the VV arm trended lower
than observed rate in the in-person arm (VV 34.6% versus IPV 50%; RR 0.69; 95% CI
0.44 to 1.09; P=0.12), without any signal of harm—no significant differences in hospital
readmission, emergency room visit, or death between the study arms.7 Yet, despite
its promise, wide utilization of VVs in the US healthcare environment prior to the
COVID-19 pandemic has been limited due to lack of familiarity with technologies among
both clinicians and patients, concerns about the safety of substituting in-person
visits with VVs, lack of integration into clinicians’ established workflows, perceived
and actual legal barriers, and limited payer reimbursement.8
In the setting of the COVID-19 pandemic, many of these barriers have now disappeared
given the importance of social distancing. The purpose of this statement is to provide
a pragmatic guide to HF clinicians about provision of VVs in the era of the COVID-19
pandemic. First, we will outline benefits and value of VVs, some of the clinical challenges,
and the recent COVID-19-related changes in policy and reimbursement that have facilitated
the uptake of VVs. Then, we will outline some of the VV platforms that currently exist
and describe models of care using VVs. Finally, we will describe the short-term and
long-term future implications of VVs.
Benefits and value of virtual visits
During the current public health emergency, VVs have multiple potential benefits (Table
). From a patient standpoint, VVs provide access to care where it has been significantly
curtailed or entirely disappeared. By providing a platform for patients to continue
to receive medical advice and instruction regarding their medical conditions, VVs
have become integral to optimizing health for patients and reducing related distress
while reducing in-person exposure. Given current restrictions on accompaniment during
visits to medical facilities, VVs have additionally facilitated involvement by patient
caregivers, who are often so critical in many of the self-care practices necessary
for adults with HF.9 Some patients may find it easier to discuss difficult topics
while in the comfort of their homes, and with family members who may not otherwise
be present for in-person visits. From a clinician standpoint, VVs permit clinicians
to continue to serve their patients from the safety of their own homes, through provision
of care to their medically complex patients. The ability for a face-to-face encounter
may be especially valuable in preserving patient-physician trust in the absence of
in-person visits. From a healthcare systems standpoint, provision of services remotely
has allowed re-allocation of resources to focus on inpatient services, which are at
risk of becoming overwhelmed and saturated given the rapidity and volume of severe
COVID-19 cases requiring acute inpatient care. Additionally, VVs allow continued delivery
of services with reimbursement that can contribute to ensuring the financial sustainability
of hospitals, practices, and the US healthcare system as a whole. Finally, VVs can
be leveraged towards ensuring continuation of research studies, where patient contact
is necessary for data collection, as well as ensuring safety of human subjects.
Benefits and value of virtual visits.
Receive medical advice
Reduce in-person exposure to SARS-CoV-2
Reduce in-person exposure to SARS-CoV-2
Maintain connection between patient and provider
Support research efforts
Challenges to virtual care
To successfully conduct a VV, patients must be willing and able, and the technology
must be available and effective. Accordingly, VVs may present some challenges in selected
circumstances. Some patients may be reluctant to participate in VVs because they feel
uncomfortable with technology, or feel self-conscious about interacting on video.
These feelings may become less common as VVs enter the mainstream. VVs present a barrier
to performing a full physical exam, though many components of a partial exam can be
completed, and existing and emerging diagnostic technologies and wearables may fill
in the gaps. This is discussed further below. Some clinicians and patients may feel
that even with the use of video, VVs are not the same as in-person visits with respect
to patient-physician interactions—something is lost without close proximity and the
“laying on of hand.” Some patients may have limited access to the internet, and/or
may not have a computer or smart device to engage in VVs, including the poor or elderly
in inner city or rural areas. Although there may be geographic and financial challenges
to obtaining WiFi for some patients, we anticipate that future technology will provide
"hotspots" via ubiquitous cellular networks alleviating most barriers to internet
access. Some health care systems are investing in these technologies and providing
equipment and connectivity to ensure that telehealth does not widen health disparities.10,
Older adults may be viewed as a subpopulation where these challenges are common. This
is particularly important because over half of patients currently living with HF in
the US is older than 70 years.12 However, recent data show that an increasing number
of older adults possess smartphones, and that some guidance to using newer technology
can be taught, possibly by hospital/clinic support teams.13 Integration of the VVs
technology platform within an institution's electronic portal or app, which is already
familiar to patients, may be another approach to overcoming these challenges.
Patients and clinicians may occasionally encounter technical difficulties when conducting
VVs. These may include an inability to initiate the VV, connectivity issues, and/or
audio/video problems. Some of this may be a direct result of larger than anticipated
volume of users concurrently attempting to use a platform in the setting of the COVID-19
crisis. Over time, the hope is that software upgrades will address these issues, and
that platforms will be able to accommodate a greater number and capacity of users.
Of note, if/when these technical issues arise, switching to a telephone visit is a
reasonable solution and remains reimbursable.
Policy changes that increase feasibility of virtual visits in the era of COVID-19
Several governing bodies, including the US Executive Branch, US Congress, US Department
of Health and Human Services (HHS), and State governments, have relaxed rules and
regulations that have subsequently increased the feasibility of VVs. In response to
the ongoing COVID-19 public health emergency the “Coronavirus Preparedness and Response
Supplemental Appropriations Act, 2020”, was passed with near unanimous support by
the US Congress and was signed into law by the President on March 6, 2020.14 This
bill allowed HHS to “temporarily waive certain Medicare restrictions and requirements
regarding telehealth services during the coronavirus public health emergency.” Then
on March 13, 2020, the President proclaimed the COVID-19 outbreak a US national emergency,
which allowed HHS to exercise its authority under section 1135 of the Social Security
Act to temporarily waive certain requirements of Medicare, Medicaid, and the Health
Insurance Portability and Accountability Act of 1996 (HIPAA).15 Specific steps taken
by HHS and States are described below, and a summary of key policy changes are shown
in Table 2
Telehealth-related policy changes in the era of COVID-19.
Key policy changes: COVID-19 pandemic
Implications for virtual visits
HHS waived requirement for health care professionals to hold license in State which
they provide services if they have an equivalent license from another state. HHS asked
States to waive local licensing requirements, with final decision made at State level.
Potentially allows to practice medicine via virtual visits across State lines.
HHS suspended HIPAA rules.
Allows use of virtual visit platforms previously deemed not HIPAA compliant.
Location of patient
CMS waived rural and site limitations for telehealth interactions.
Allows clinicians to be reimbursed for telehealth services regardless of patient's
Prior existing relationship
CMS waived requirement that telehealth services can only be provided to a clinician's
Clinicians can see new patients by telehealth.
DEA relaxed rules related to prescription of controlled-substances by telehealth.
Clinicians can prescribe controlled-substances in setting of a virtual visit.
CMS, Centers for Medicare & Medicaid Services; DEA, Drug Enforcement Administration;
HHS, US Department of Health & Human Services; HIPPA, Health Insurance Portability
and Accountability Act
HHS has eased a variety of rules that relate to medical licensing and privacy, which
directly affect telehealth practice. First, the requirements that both physicians
and other health care professionals hold licenses in the State in which they provide
services were waived by the Federal government.16 Second, HIPAA privacy rules were
suspended. Specifically, HHS indicated that it will “exercise its enforcement discretion
and will not impose penalties for noncompliance” with HIPAA rules as they relate both
to telehealth technologies, and the manner in which they are used.17 This is important
because clinicians are now allowed to deliver medical care via any non-public facing
VV platform, even if not previously deemed HIPAA compliant. In the short-term, this
increased flexibility may lead to increased uptake of VVs. In the long-term, we recommend
that HF clinicians use HIPAA compliant platforms whenever possible, both for extra
security and to develop practices and habits that will be relevant in post-pandemic
States have individually taken a variety of steps to remove barriers to VVs in the
setting of the COVID-19 pandemic. These relate to Medicaid reimbursement, licensing,
and home eligibility site. The Center for Connected Health Policy is maintaining a
comprehensive State-specific summary of these, which can be found on its website (https://www.cchpca.org/resources/covid-19-related-state-actions).
Recent changes in reimbursement for virtual visits
Reimbursement for VVs was limited prior to the COVID-19 public health emergency. With
just a few exceptions, CMS reimbursed for telehealth visits only in specific circumstances:
patients had to have an established relationship with their physician, had to live
in a rural area, and had to be located in a medical facility at the time of the VV
(“originating site”). Many commercial insurance providers reimbursed urgent care VVs
(i.e., substitution of in-person emergency room or urgent care visits), with only
a small number reimbursing for primary care or specialty care VVs. Meanwhile, some
hospitals have started offering VVs in selected settings for certain high-risk conditions
(including HF), spending institutional resources in hopes that long-term savings through
bundled payment models would ultimately compensate for the associated costs of VVs,
while others have offered VVs in exchange for direct cash payment from patients.
In March 2020, following announcement of the COVID-19 public health emergency and
the 1135 Waiver, several important telehealth-related reimbursement changes occurred.
CMS announced that VVs, referred to as “telehealth visits” in CMS documents, would
be reimbursed at the same rate as in-person visits during the COVID-19 crisis, without
limits on the purpose of the visits, the geographical location of patients, and whether
or not there was a previously established relationship with the provider. Multiple
commercial insurance providers including Aetna, Cigna, Humana, and Blue Cross Blue
Shield among others have followed suit. Waivers of beneficiary co-pays for these telehealth
services vary among these providers.
To secure reimbursement at the current time, documentation for VVs should approximate
documentation for in-person ambulatory clinic visits. We recommend that clinicians
explicitly document that a virtual (audio/video) visit was completed, with the patient's
consent. Clinicians should document the amount of time it took to conduct the visit
in minutes. Specific CPT billing codes and relevant modifiers are shown in Table 3
. The future state of EHR documentation for VVs may include capture of images or streaming
clips of video interactions, automated transcription of key components of the conversation,
and use of natural language processing to determine meaning and summarize information.
Billing codes for virtual visits (also called “Telehealth visits” by the Centers for
Medicare & Medicaid Services).
Code and Modifier
Office or other outpatient visit for the evaluation and management of a new patient
CPT Code 99201-99205*
Place of service 02 for Telehealth (Medicare), or,
Modifier GT (Medicare/Medicaid)
Modifier 95 (Commercial payers)
Office or other outpatient visit for the evaluation and management of an established
CPT Code 99211-99215*
Place of service 02 for Telehealth (Medicare), or,
Modifier GT (Medicare/Medicaid)
Modifier 95 (Commercial payers)
Telehealth consultations, emergency department or initial inpatient
G0425 – G0427
Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals
or skilled nursing facilities
G0406 – G0408
*Choice of CPT code depends on whether the provider elects to use time-based coding
versus component-based coding. For example, a provider using time-based coding for
a Medicare beneficiary seen by VV for 15 minutes would document the time spent in
their note, and then may choose CPT code 99213 with modifier GT, if otherwise appropriate
to that encounter.
Virtual visit platforms
According to HHS, “a covered health care provider that wants to use audio or video
communication technology to provide telehealth to patients during the COVID-19 nationwide
public health emergency can use any non-public facing remote communication product
that is available to communicate with patients.” Non-public facing products are typically
platforms that employ end-to-end encryption, and which allows only an individual and
the person with whom the individual is communicating to see what is transmitted. On
the other hand, public facing platforms (i.e., Facebook Live, Twitch, and TikTok)
are designed to be open to the public or allow wide or indiscriminate access to the
communication. Table 4
outlines and describes some common platforms that may be used for VVs.
Virtual visit platforms utilized during COVID-19 public health emergency.
Popular applications that allow video chats
Facebook Messenger video chat
Allowed during COVID-19 crisis, but less secure
Google Hangouts video
Providers are encouraged to notify patients that these third-party applications may
introduce privacy risks
Providers should enable all available encryption and privacy modes when using
Use may expose provider's personal information (email account, telephone number, etc.)
Specialized technology platforms
Skype for Business / Microsoft Teams
Partial list of HIPAA compliant technology platforms
Under normal conditions HIPAA business associate agreements for provision of telehealth
services are required, but this was waved as part of COVID-19 crisis
Zoom for Healthcare
Google G Suite Hangouts Meet
Cisco Webex Meetings / Webex Teams
• Variability in cost and functionality
Spruce Health Care Messenger
BlueJeans for Healthcare
HIPAA, Health Insurance Portability and Accountability Act
Virtual visit models of care
Which patients should be seen by virtual visits?
VVs can be used to evaluate the full range of patients with HF, including those with
HFpEF and HFrEF, across all Stages of HF (A-D), and including those with left ventricular
assist devices (LVADs) and heart transplant recipients. Clinical assessment provided
over VVs can include evaluation of clinical status, medication review and management,
screening for adverse events, up-titration of guideline-directed therapy, and counseling
about topics related to medication adherence, diet, and exercise.
In general, outpatient visits may be classified as urgent or routine. The urgent classification
includes visits for new or worsening HF symptoms, or are applicable to patients with
recent LVAD implantation or heart transplantation. Using VVs to manage and triage
complaints of dyspnea may be especially important during the COVID-19 crisis, given
the importance of differentiating worsening HF from acute COVID-19 that could very
rapidly deteriorate to respiratory failure. Individuals who are nearing Stage D HF
and/or those requiring inotropes may also be important priorities due to their potential
to decompensate. Routine visits could include those focused on medication titration,
new test results, or time-interval associated visits. Many HF programs across the
country have already converted in-person visits into VVs, keeping patients in the
same previously scheduled date and time slots.
Both urgent and routine visits may be conducted via VVs, depending on resource availability.
An algorithm that clearly differentiates urgent from routine visits may be helpful
for allocating resources. Administrative personnel and/or nurses should be trained
to triage effectively according to each practice's preferences. Clinicians may also
use VVs to screen urgent complaints, and decide which patients need to be seen in-person.
Importantly, a variety of HF clinicians including physicians, advanced practice providers,
and licensed social workers, can perform and be reimbursed for VVs.18 Pharmacists
can provide VVs as well, but billing would have to occur through their supervising
physician.19 Clinicians who require quarantine, but are well enough to practice, may
provide an additional workforce to conduct VVs while their in-person contributions
are limited. Although it is preferred that VVs occur between the patient and their
usual HF clinician and team, it may be necessary in some cases for clinicians to conduct
VVs with colleagues’ patients; this will likely vary across healthcare systems.
What is the clinical workflow of a clinic/office practice performing telehealth virtual
VVs can be engineered to approximate traditional in-person visits (Table 5
). During these visits, various personnel can obtain a history, conduct a medication
reconciliation, review allergies, perform a review of systems, and subsequently document
patient-reported vital signs. Leveraging VVs toward medication review by video (Figure
) is particularly appealing given the number of medications that patients with HF
take and the associated risk for medication errors and adverse drug events.20 To do
this, clinicians can ask patients to hold pill bottles up to the camera for the clinician
to visualize and review. VVs might actually be superior to a usual in-person clinic
visit in this regard, since pill bottles are infrequently brought to in-person appointments.
Preparations for a successful virtual visit.
Before the VV
• Determine which platform and technology will be used for the VV, and ensure that
your patient can engage.
• Ensure that the patient has consented for VV (verbal or written).
• Position yourself centered in front of your webcam, smartphone or tablet. Adjust
lighting in the room.
• Confirm that video and audio are functioning appropriately.
• Consider having your EHR open for live review during the VV, either on another screen
or using split screen configuration.
• Follow VV etiquette: conduct visit in a private professional appearing space, make
sure there is no background noise or distractions, mute your audio connection when
• Collaborate with support staff who may contact patients in advance to obtain vital
signs, perform medication review, and confirm time the clinician will call. This will
vary by practice.
During the VV
• Confirm that patient's audio and video connection is established.
• Maintain visual eye contact.
• Ensure patient's readiness to begin. If distractions are noted, ask to minimize
• Determine if this is their first experience with VV and acknowledge uneasiness if
any. Let the patient know they can interrupt at any time, if they have issues with
the platform, or the visit in any way
• Guide the patient through maneuvering the camera for a physical examination.
• Address need for laboratory studies.
• Use teach-back and ask the patient to write down important instructions, medication
changes, and their follow up plan. Reinforce usual self-care.
• End the visit with asking the patient how the experience was for them, what worked
well, what could be better and use this for planning future visits.
After the VV
• Document in the EHR: VV performed with a VV attestation and time spent, nature of
the visit and who was present. Consider a specific designation for the note (e.g.,
Heart Failure Virtual Visit).
• Email, mail, or message patient any medication updates or specific instructions
• Arrange for laboratory testing, if needed.
• Bill for the encounter.
• Plan for the next visit.
Screen shots from video virtual visits between a HF cardiologist (right lower hand
corner) and a patient. (A.) Medication review by video. (B.) Examination of ankles
showing sock markings without edema, and (C.) neck examination.
Basic components of the physical exam can be performed via telehealth, especially
when patients use high-quality video equipment available on contemporary smartphones
and tablets (Figure 1). These components may include general appearance, including
alertness and orientation, as well as an assessment of volume status by looking for
signs of peripheral edema such as leg swelling, and/or remote evaluation of neck veins.
Assessment of neck veins is best done with a second person moving the camera position
relative to the patient's neck in order to obtain the appropriate angle and lighting.
Recent data have demonstrated that assessment of neck veins with video magnification
technology correlates with invasively measured right atrial pressure.21 Assessment
of orthopnea and bendopnea may also be done remotely, both of which are associated
with elevated ventricular filling pressures.22, 23 VVs may also permit an assessment
of exercise intolerance, for example by asking the patient to walk from room to room
or up a flight of stairs. Finally, it is possible to use VVs to examine peripherally
inserted central catheter line sites and other cannulae, as well as healing surgical
incisions such as pacemaker or ICD implantation sites.
Adjuncts to virtual visits
Several remote monitoring capabilities are already in use for the care of patients
with HF and can complement data collected during VVs.24 The most basic is remote monitoring
of weight and blood pressure via electronic scales and blood pressure cuffs. CardioMEMS,
a hemodynamic monitor implanted into the pulmonary artery that remotely transmits
pulmonary artery pressures, has been shown to reduce hospital readmissions and improve
quality of life, and thus may be used in addition to telehealth visits to guide therapy.25,
26 Similarly, remote ICD interrogation to assess arrhythmia burden can provide additional
information. Whether wearable devices for ambulatory cardiac monitoring such as wristwatches,
smartphones, patches, headbands, eye-glasses, necklaces, or vests can be integrated
into clinical management provided through VVs is unknown, and warrants future investigation.27-29
Advance care planning
VVs provide a unique opportunity to engage patients and caregivers on topics related
to advance care planning, which are of heightened importance during the COVID-19 pandemic,
especially among higher risk populations. Conducting these conversations while the
patient (and their caregivers) are in the comfort of their own homes may provide the
optimal setting for these discussions. As the COVID-19 crisis unfolds, issues related
to becoming acutely ill may very well be on the minds of many patients with HF. Accordingly,
it may be appropriate to discuss care preferences during VVs. Questions that may be
routinely incorporated into the discussion include:
“Have you appointed a health care proxy?—this is a person who would make decisions
on your behalf if you were unable to make decisions.”
“Have you completed an advance directive form?”
“Does your health care proxy and/or family know what your care preferences would be
if you were to get sick and could not make decisions for yourself?”
“Do you have a healthcare power of attorney form?—this is a legal document that gives
one person the authority to make health care decisions for you if you are unable to
Pharmacy considerations following a virtual visit
One of the major goals of VVs is to reduce exposure to others who could be potentially
infected by the SARS-CoV-2 virus. Consistent with this goal, it is equally important
to consider patient strategies for obtaining medications that permit social distancing.
Delivery of medications to the patient's home is one method to reduce exposure. Approximately
20% of patients historically use mail delivery pharmacy services, which means the
majority of the population will need to navigate this process for the first time during
the current public health crisis.30 National mail-delivery pharmacies may be a long-term
solution for many patients, but new patients and/or prescriptions will typically experience
a 1-2 week delay before delivery. It may thus be prudent to use independent and chain
pharmacies, many of which can deliver medications within their communities on the
same or next day. Of note, various pharmacy chains have waived delivery fees during
the COVID-19 crisis. For patients unwilling or unable to use these services, selecting
a pharmacy location with a drive-up window may provide an alternative solution that
permits some degree of social distancing.
Clinicians should consider prescribing a 90-day supply when appropriate and helping
patients synchronize all medication refills to a common schedule to reduce the number
of trips to a pharmacy; especially now that many of the traditional legal and administrative
barriers to these efforts have been removed for COVID-19. Both CMS Part D sponsors
and commercial pharmacy benefit managers have relaxed restrictions on early refills
and now allow the maximum day supply (most commonly 90 days) for medications to be
filled. Additionally, many States have instituted emergency actions to facilitate
medication access such as allowing pharmacies to dispense an emergency 30-day supply
of chronic, non-controlled medications when patients are awaiting refill authorization
from providers. A continually updated list of pharmacy-related state actions impacting
medication access sorted by State is available at the National Alliance of State Pharmacy
Associations website (https://naspa.us/resource/covid-19-information-from-the-states).
Inpatient use of telehealth
While this statement is primarily focused on leveraging VVs for continued ambulatory
care of adults with HF, these principles also apply to the inpatient setting. Given
concerns about shortages in personal protective equipment, VVs may be beneficial to
clinicians working in the inpatient setting, and have already been implemented by
some healthcare systems across the US. Approaches vary but most commonly involve the
use of either hospital-provided or the patient's own smartphone or tablet. Software
platforms reportedly being used include Apple FaceTime, Cisco Jabber, and Microsoft
Team among others, some of which allow multiple team members to connect and conduct
virtual rounds together. These visits may be enriched by the use of Bluetooth stethoscopes
and/or point-of-care ultrasound technology that can provide valuable information about
the physical exam while limiting exposure. Of note, VVs for inpatient care are reimbursable
(Table 3) and equivalent to in-person hospital service. If the consultant is outside
of the hospital and the patient is in the hospital, these inpatient encounters can
be billed as an ambulatory telehealth visit.
Future of virtual visits after resolution of the COVID-19 pandemic
COVID-19 has saturated some hospitals with high volumes of patients with respiratory
syndromes and respiratory failure, and subsequently forced the medical community to
rely on VVs to provide routine care to many patients with chronic medical illnesses
like HF. Importantly, survivors will likely require prolonged time for recovery, and
it remains unclear where these patients will recover and rehabilitate. At the present
time, many rehabilititation and long-term care facilities do not accept patients who
were COVID-19 positive, due to concerns about disease transmission. It is therefore
possible that some US hospitals will remain at capacity well-beyond the time period
of the COVID-19 surge. Additionally, emerging data suggest that at least 20% of COVID-19
positive patients are health care providers, which will stretch the active work force
even further. Thus, continuing resource-efficient strategies like VVs may be necessary
for the near and intermediate future.
It is unclear what the psychological impact of COVID-19 will be on providers and patients,
especially among those patients who are at highest risk—which include those with chronic
conditions like HF. An important consideration is that, even after the COVID-19 crisis
ends, patients may continue to have concerns about in-person office visits and travel,
and prefer to continue with a degree of social distancing. As a result, many patients
with HF may continue to prefer VVs. Prior to the COVID-19 pandemic, there was little
impetus for clinicians to learn or embrace VVs. In the current era, many clinicians
have been forced to learn and use VVs. Consequently, as we move beyond the COVID-19
pandemic, clinicians may be more amenable to VVs; in fact, some may even prefer them.
With these expectations in mind we believe that VV models of care will become the
norm in the US healthcare system moving forward, especially for patients with HF.
Many patients with HF, especially older adults with disabilities, and those living
in rural communities often have difficulty attending in-person visits due to very
poor exercise tolerance, inadquate transportation, and difficulty transporting oxgyen
among other barriers. For these patients VVs are certainly more convenient, and likewise
for their caregivers, who sometimes have to take off work to bring their family member
to the appointment.
Policy and reimbursement practices developed in response to the COVID-19 public health
emergency and discussed in this document may remain and further evolve to accommodate
continued use of VVs. We suspect that it is possible if not likely that CMS will continue
incenting VVs, though likely at lower reimbursement rates than in-person visits. Distance
health technologies that align with VVs, including biosensing wearables28, 31 and
other diagnostic tools, may be increasingly adopted. Whether the use of VVs can improve
adherence, decrease no-show rates, decrease office overhead, improve transitions of
care from the inpatient to outpatient setting, or prevent ER visits and hospital admissions/readmissions
for patients with HF is yet unknown. This underscores the need to collect outcomes
data. While frightening to consider, we will be better able to pivot when the next
pandemic comes along with VV systems in place. Regardless, the COVID-19 pandemic has
generated an important opportunity to learn about delivering HF care in a different
way that should be fully embraced well beyond the current crisis.
No relevant conflicts of interest.
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