Year: 2020
Type: article
Abstract: In the shadow of the COVID-19 pandemic, the opioid crisis continues as opioid addiction and overdose deaths persist nationwide, and new restrictions present challenges to pain and opioid management for surgical patients. Acute surgical pain exacerbations, in conjunction with limited access to social, mental, and medical resources [1, 2], increase the risk of excess opioid prescribing, as well as the risks of opioid diversion, misuse, and dependency [3]. These may manifest in unnecessary emergency department visits and hospital admissions and increased rates of drug overdose and suicide [4]. Health care systems must adapt to provide services for surgical patients [2]. Telemedicine allows real-time, audio–video communication between patients and clinicians in remote locations [5] and can potentially address the novel challenges to pain management for surgical patients during the pandemic [6, 7]. Nascent literature has demonstrated increased utilization and acceptability of telemedicine services in the United States [8, 9]. Benefits include saving travel time and cost, reducing missed visits, and improving inter-clinician communication [10] without compromising quality of care. A randomized clinical trial comparing telemedicine with usual care for rural veterans with post-traumatic stress disorder showed that patients using telemedicine were engaged in psychotherapy and had reduced post-traumatic stress disorder symptoms as compared with patients using usual care [11]. Despite the benefits, telemedicine alters traditional patient–provider relationships [12]. The high cost of implementation and maintenance may render services unaffordable [13]. Telemedicine may inadvertently widen health care disparities if patients lack access to or ability to use technology [14–16]. A system-wide approach is necessary to manage knowledge gaps in confidentiality and Health Insurance Portability and Accountability Act (HIPAA) compliance [10]. To address the opioid crisis, the PPP has coordinated care for surgical patients on long-term opioid therapy and for opioid-naïve patients at risk of long-term opioid therapy by using a personalized pain management plan centered on multimodal and regional techniques [17–19]. A prospective study of PPP patients showed significant reduction in morphine milligram equivalent, improved pain scores, and improved self-reported physical function for postoperative patients on long-term opioid therapy [8]. To provide services for new patients undergoing urgent or emergent surgeries and for preexisting patients, the PPP has transitioned to telemedicine. Table 1 describes adaptations to the PPP operation [20]. Adaptations of PPP work systems and processes for telemedicine Clinicians Had preexisting access to a prescription drug monitoring program Received authorization to electronically prescribe controlled substances Clinic coordinator Trained in establishing the telemedicine platform with patients Patients Received instructions by e-mail on installing and launching the telemedicine platform before their visit Before visit Clinic coordinator obtained patient consent for a telemedicine visit, confirmed patient access to telemedicine platform, and emailed patient-reported measures survey to the patient During visit Clinician obtained patient consent to telemedicine visit (if not consented before visit), confirmed patient identity and contact information (to call patient in case of technology failure), completed history, and electronically prescribed medications (including controlled substances) After visit Patient received visit summary in electronic medical records Clinic coordinator scheduled follow-up visit and served as liaison if patient has follow-up questions PPP providers communicated via email rather than in person HIPAA-compliant platform Non–HIPAA-compliant platforms Prescription drug monitoring program Virtual Guidance on using (non–) HIPAA-compliant telemedicine platforms Guidance on scheduling appointments for out-of-state patients (with private insurance) As a clinic within a tertiary academic medical center, the PPP continues to receive referrals for patients undergoing urgent or emergent surgeries during the COVID-19 pandemic. To continue providing care for these patients and for established patients who are undergoing opioid tapers that are individualized to their needs, we transitioned PPP to telemedicine by using the existing infrastructure at Johns Hopkins. The COVID-19 public health emergency declared by the US Secretary of Health and Human Services allows providers to prescribe controlled substances without conducting in-person visits. Table 1 describes adaptations to the PPP work systems and processes to ensure a successful transition to telemedicine [20]. Our experience has outlined the importance of a coordinator for scheduling and bridging communication. Patients and providers have accepted the use of telemedicine and are flexible in managing technology failure. Patients are grateful that their pain management and access to medications have not been disrupted. The length of the workday has not increased. As clinic space is not a limiting factor, scheduling flexibility has improved. E-prescribing and access to prescription drug monitoring databases remain vital. Challenges have included difficulty building rapport with new patients, reduced ability to assess pain by observation of nonverbal pain behaviors, inability to collect vitals or a urine toxicology at the time of visit, limited physical exam, and absence of family members to collaborate collateral information. There is concern about burnout from excessive use of technology. Collectively, we have found that the benefits have outweighed the challenges. Since the PPP adapted its response to the COVID-19 pandemic, 116 patients have had 146 telemedicine encounters. On the basis of preliminary responses, patients have been satisfied with their telemedicine visits and believed that it improved their access to the clinic (“It is a long distance from my house to the clinic. When I was a fresh post-operative patient, it was very hard.”), mitigated the risk of COVID-19 (“I do not have to worry about picking up a virus.”), and facilitated the engagement of their family members (“The video allows my families to be involved too.”). On the other hand, patients indicated that patient–clinician communication was hindered by telemedicine (“I find it much easier to talk in person, not online.”) and that they needed assistance to facilitate the use of the telemedicine system (“Patients need more assistance on how to use the system.”). Further analysis is under way to assess the impact of telemedicine on access to, quality of, and clinical outcomes of perioperative pain management, which will be addressed in a future study. At this time, the PPP is offering both on-site and telemedicine visits. Almost all of the visits are telemedicine. New patients are encouraged to come to the clinic, while established patients can decide which modality they would like to use to continue their care. Many patients have already expressed their preference to continue using telemedicine—a preference predictably seen in patients who are out of state. Patients who require more frequent urine toxicology screenings or with greater medical acuity are seen in the clinic. We predict that telemedicine will become an integral part of our practice and anticipate that 50% of our practice may remain this way during the remainder of the COVID-19 pandemic and possibly afterward. This is pending barriers in reimbursement and state licensure laws, as current telemedicine restrictions are transient during the duration of the CARES Act [21]. In the midst of the COVID-19 pandemic, the PPP’s innovative transition to telemedicine has allowed us to provide continuity of care for patients. Further investigation is needed to assess whether telemedicine for pain management is efficacious as compared with in-person visits and if access to and quality of perioperative pain management are maintained. If effectiveness, access, and quality are equivalent, our program may serve as a model to adapt telemedicine for vulnerable patients with limited access to pain management and mental health specialists. Correspondence to: Sarah Rahman, MD, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Sheik Zayed Tower 8120L, 1800 Orleans Street, Baltimore, MD 21287, USA. Tel: 410-955-1818; Fax: 410-955-0270; E-mail: [email protected]. Funding sources: No funding sources. Conflict of interest: No conflicts of interest. Disclosure information: No disclosures.
Source: Pain Medicine
DOI: 10.1093/pm/pnaa336
Institutions: Johns Hopkins University, Johns Hopkins Medicine
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W3085778806