Allergy Telemedicine Effective, but Regulations Must Change

Ingrid Hein

June 05, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Allergists in the United States, who have been slow to adopt telemedicine, have been forced to step up their game in the wake of COVID-19.

The hospital-wide adoption of telemedicine "went from 2% to 60% overnight," said Jay Portnoy, MD, from Children's Mercy Hospital in Kansas City, Missouri. "Our hospital was seeing about 400 patients a month via telemedicine; now we see 600 to 700 a day."

This was a big change in practice for the allergy and immunology department, Portnoy told Medscape Medical News. Allergists and immunologists had one of the lowest rates of telemedicine adoption, at 6.1% in 2016, according to a 2018 study. In contrast, rates were 24.1% in cardiology, 38.8% in emergency medicine, and 25.5% in radiology.

"It was thought that because of skin tests and food challenges, it had to be done in person," he explained. "But necessity is the mother of invention; you take away the roadblocks and telemedicine works."

Patient Satisfaction

Portnoy has been advocating for increased telemedicine use for years. "It has never been patients or hospital support that has made it difficult to practice telemedicine," he said. He presented findings from a survey on the subject at the American College of Allergy, Asthma & Immunology 2019 Annual Scientific Meeting.

Of 299 pediatric allergy and immunology patients in his hospital's telemedicine program, 187 (63%) said they were equally satisfied with in-patient and telemedicine visits, 112 (37%) said they were more satisfied with telemedicine, and no patients said they were less satisfied with their telemedicine visit.

As to why they liked it better, 76% said they preferred telemedicine because of distance and convenience.

"Only a very few patients say they prefer in-person visits; usually it's the ones who have technical problems," Portnoy told Medscape Medical News.

He will be presenting his research and experience with telemedicine during a symposium at the European Academy of Allergy and Clinical Immunology Digital 2020 Congress.

We had to come up with infrastructure, a scheduling platform to notify patients, and regulatory documents all in a 2-week period of time.

Until now, the issues have "been mostly about regulatory barriers," Portnoy reported. Regulators and insurers have been concerned that there will be widespread abuse and that it will cost more.

"Payers and legislators have been reluctant to lift barriers; all 50 states plus the District of Columbia have made different rules and regulations for telemedicine. The only consistent one is Medicare, but it's really restrictive," he said.

Medicare limits how far away a patient can live from a provider organization by region, and only a certain subset of children can be treated, in highly specific ways.

But "when COVID struck," the barriers were lifted. "We had to come up with infrastructure, a scheduling platform to notify patients, and regulatory documents all in a 2-week period of time," Portnoy said. "It turns out that when you need something, you can do it quickly."

"Now we have a waiver and can see people while they're at home and we no longer have to do a physical workup to develop a patient–physician relationship," he said.

That makes telemedicine a whole lot easier to integrate into a practice.

"Everyone is now saying it's surprisingly easy and more efficient," he said. "Physicians thought that patients would be unhappy, but they really like it; they find it convenient."

We're finding that allergists can do telemedicine for just about every patient.

"There was concern that asthma could not be treated without spirometry," Portnoy said. "But we are finding that you can treat asthma patients just as well with and without spirometry. Now that we can't use it, we don't seem to be disadvantaged."

In fact, "we're finding that allergists can do telemedicine for just about every patient," he added. "We treat based on symptoms." Prescriptions are sent to the pharmacist and patients can get the treatment they need.

Before COVID-19, allergists insisted that they needed to see patients in person for skin testing, said Portnoy. "With telemedicine, we go for a blood test. It works just as well; I've been doing blood tests for a decade."

The only difference is that "it just doesn't bring in as much revenue," he noted. Skin tests are billed by the allergist, "but blood tests are billed by a lab."

"Financial incentives can be corrupting," Portnoy said.

Looking to the Future

The American Telemedicine Association (ATA) is advocating for physicians to be better supported to practice telemedicine, and is asking for increased funding and changes to regulations.

At the start of the pandemic, Ann Mond Johnson, chief executive officer of the ATA, sent a letter to members of Congress outlining the barriers to telehealth. She asked for funding to expand telehealth services, for another $300 million for the FCC COVID-19 Telehealth Program, and for access to be expanded to include public nonprofits.

She also asked for prioritization of telehealth policy, inclusion of telehealth in the National Health Security Strategy, a review of outdated restrictions on telehealth, expansion of the Healthcare Connect Fund, and funding for the Public Health and Social Services Emergency Fund.

She is also requesting removal or amendment of "antiquated barriers that have long prevented our nation from leveraging the power of telehealth to expand access, improve quality, and reduce costs."

"The new realities of health care delivery in a post-COVID-19 world will necessitate the continued use of telehealth to support social distancing and maximize health care resources. Further, the continuation of many temporary policies, and enactment of new, permanent statutory and regulatory changes, will be needed as America returns to 'normal'," Johnson said in a press release.

Once COVID restrictions are lifted, clinicians "will have to fight" to continue to be reimbursed the same amount for telehealth as for in-hospital care, said Portnoy.

The marked increase in the adoption of telemedicine will likely continue but, he acknowledged, there are some treatments that cannot be given through telemedicine, mostly because of anaphylaxis risk, such as allergy shots and oral food challenges for desensitization.

Immunotherapy up-dosing is also something that comes with anaphylaxis risk. Since COVID restrictions have been in place, patients have not been able to get immunotherapy treatment. "If the disruption goes on too long, we may need to decrease dosing," Portnoy said, which will result in prolonged therapy.

"Telemedicine is fast becoming part of how health care is delivered. It is no longer considered novel," Morgan Waller, RN, MBA, director of telemedicine business and operations for Children's Mercy Hospital, is quoted as saying in a 2018 Children's Mercy report. "It improves access to our services; enhances outreach efficiency and quality; and is more convenient for patients, families and providers."

European Academy of Allergy and Clinical Immunology (EAACI) 2020 Congress.

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