Are You a Doctor Starting Telemedicine From Home During COVID-19? Here are Three Things You Should Not Worry About

Mar 20, 2020

Your hospital or practice has asked you to use telemedicine from home and you already have enough to worry about without worrying about the technology. The TLDR version:

You almost certainly have a good-enough Internet connection.
HIPAA is not a barrier - you can use whatever platform makes sense for you and your patient.
In some states you will get paid for it (for other than Medicare patients - rules are unfolding in real time for Medicare.)

Here are three things that might help set your mind at ease.

1. You Probably Have Enough Bandwidth

Unless you still use a dial-up modem, even a basic broadband package should have more than enough bandwidth to support voice, video, and other needs while you conduct visits from home. Skype lists 128 Kilobits per second (Kbps) is the minimum for a video call on that platform. 1.2 megabits per second (Mbps) will handle high-definition video and voice. Better than HD TV quality can be run over approximately 7 Mbps. For some perspective, the cheapest broadband package I can find in my Massachusetts neighborhood provides 60 Mbps download and 10 Mbps upload. This is more than enough to support voice, video, and more.

Caveat: Unless you live alone, you're likely sharing your connection right now with children and perhaps a spouse also working from home. The total usage of everyone may need to be accounted for, but still, most broadband connections have more than enough bandwidth to support video conferencing. Today my teenage daughter was home from school and my wife was also working from home with me. At one point we had a WebEx video conference running in my office, my daughter was streaming music, and my wife was streaming a video feed to our TV. My bandwidth use didn't top 5 Mbps for all of that combined.

The same connection quality parameters that will yield good voice calls will yield quality video calls. Measurements of more than just throughput (bandwidth), including latency and jitter will ensure that your connection is up to the job. If you'd like to check your connection, you can use some online tests for voice over IP (VOIP) telephony including:

https://www.megapath.com/speedtestplus/ (the simplest - gives a green/yellow/red evaluation score)
http://voipqualitytest.com/
https://www.nextiva.com/resources/voip-speed-test.html

2. HIPAA is not a Barrier

Privacy is still important, but if your organization is trying to respond to the COVID-19 pandemic, HIPAA is not a barrier. Use the tools that you and your patients have at your disposal to provide the care your patients need. On March 17th the Office of Civil Rights Enforcement (OCR), the agency tasked with enforcing HIPAA, issued a notice that they would shield any provider acting in good faith while delivering care during the COVID-19 emergency. Specifically, they said,

Today, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced, effective immediately, that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency.

3. If you are a Provider in Massachusetts (or Texas) and Your Patient isn't covered by Medicare, You'll get Paid. (Medicare rules are catching up.)

On March 15, Massachusetts Governor Charlie Baker signed an Order Expanding Access to Telehealth Services and to Protect Health Care Providers. Among other things this order requires all regulated insurance carriers in the Commonwealth to, "allow all in-network providers to deliver clinically appropriate, medically necessary covered services to members via telehealth." It also requires payment parity with in-person services, and requires carriers to waive co-pays and other cost-sharing for patients. If you are practicing in another state, you may need to check to see if your authorities have issues similar orders.

Update 3/19/20: Texas has issued a similar order.

So what should you think about?

Your computer. Internet bandwidth probably won't cause video or audio problems, but your computer might. Most video quality problems have more to do with limited memory in your PC/tablet or old, slow processors than they do Internet bandwidth problems. Try to close anything you don't absolutely need to have running during a conference or consider having a dedicated device for the video connection and using something else like a mobile device for access to your EHR or other systems. Also, reboot your computer every day to make sure every program has truly purged itself from memory.
Your home network. Home wireless networks may be the real bottleneck. If you are connecting to the Internet via a wireless router, your Internet bandwidth might not be the problem. Really old wireless routers might only be capable of actually delivering 5 Mbps. Even newer routers might deliver only 54 Mbps on a good day. And the bandwidth on the box might not be what you get in real life because of the way the router works, other signals in your area, and other factors. Lifewire has a great article about this. Whenever possible, plug a real cable directly into your wireless router or modem.
Using only what you need. Use the least bandwidth that you need. High definition video isn't always necessary. The sheer number of people all at home now working and streaming entertainment are putting unprecedented strain on the Internet. The EU has already called for streaming companies like Netflix to limit bandwidth to standard definition. We can all do our part to help the Internet stay strong when it's needed by limiting our use, especially during peak hours.
The security of your computer and your facility network. As a clinician, you might consider "quarantining" your work laptop. Although you may be forced to use new software or patients may ask to use familiar technology like Skype, now is not the time to be adding new and unfamiliar programs to the computer that attaches to your hospital network. We have already seen attacks using coronavirus tracking sites and apps. You might consider adding new software and doing video on one machine and keeping your work laptop or system "clean" from new software. Your CISO will thank you for it.