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Ten Rules for Implementation of a Telemedicine Program to Care for Patients with Asthma

2020; Elsevier BV; Volume: 9; Issue: 1 Linguagem: Inglês

10.1016/j.jaip.2020.10.005

2213-2201

Yudy K. Persaud, Jay M. Portnoy,

Social Media in Health Education

During the coronavirus disease 2019 (COVID-19) pandemic, the use of telemedicine changed from being an optional way to see patients to becoming a necessity. It has transformed primary, specialty, and mental health services by becoming incorporating into everyday practice. Because allergists have adapted to patient care using telemedicine, use of this technology is likely to continue after COVID-19. In the process of using telemedicine, lessons have been learned. We now offer 10 rules for creating a successful telemedicine practice while also ensuring that quality asthma care is provided. During the coronavirus disease 2019 (COVID-19) pandemic, the use of telemedicine changed from being an optional way to see patients to becoming a necessity. It has transformed primary, specialty, and mental health services by becoming incorporating into everyday practice. Because allergists have adapted to patient care using telemedicine, use of this technology is likely to continue after COVID-19. In the process of using telemedicine, lessons have been learned. We now offer 10 rules for creating a successful telemedicine practice while also ensuring that quality asthma care is provided. According to the American Telemedicine Association, telemedicine (TM) is the "the remote delivery of health care services and clinical information using telecommunications technology."1American Telemedicine Association (ATA)Telehealth Basics.https://www.americantelemed.org/resource/why-telemedicineDate accessed: June 4, 2020Google Scholar The use of TM to care for patients with asthma and allergies has increased recently, and its use has accelerated in response to coronavirus disease 2019 (COVID-19). Types of live (or synchronous) TM visits that have been used for asthma care include direct to consumer (DTC) and facilitated virtual visits (FVVs). Asynchronous methods to care for asthma have included remote patient monitoring (RPM) and use of mobile health (m-Health) applications. Asthma is a challenging condition to manage because it presents with varying severities, a multitude of triggers, and variable responsiveness to treatment. TM has been used successfully to improve asthma control, decrease its severity, and provide a better quality of life while improving medication adherence and decreasing use of health care resources.2Kew K.M. Cates C.J. Home telemonitoring and remote feedback between clinic visits for asthma.Cochrane Database Syst Rev. 2016; : CD011714PubMed Google Scholar, 3Lin N.Y. Ramsey R.R. Miller J.L. McDowell K.M. Zhang N. Hommel K. et al.Telehealth delivery of adherence and medication management system improves outcomes in inner-city children with asthma.Pediatr Pulmonol. 2020; 55: 858-865Crossref PubMed Scopus (35) Google Scholar, 4Portnoy J.M. Waller M. De Lurgio S. Dinakar C. Telemedicine is as effective as in-person visits for patients with asthma.Ann Allergy Asthma Immunol. 2016; 117: 241-245Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 5Sheares B.J. Mellins R.B. Dimango E. Serebrisky D. Zhang Y. Bye M.R. et al.Do patients of subspecialist physicians benefit from written asthma action plans?.Am J Respir Crit Care Med. 2015; 191: 1374-1383Crossref PubMed Scopus (50) Google Scholar, 6Stukus D.R. Farooqui N. Strothman K. Ryan K. Zhao S. Stevens J.H. et al.Real-world evaluation of a mobile health application in children with asthma.Ann Allergy Asthma Immunol. 2018; 120: 395-400.e1Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 7Toelle B.G. Ram F.S. Written individualised management plans for asthma in children and adults.Cochrane Database Syst Rev. 2004; : CD002171PubMed Google Scholar Brown and Odenthal8Brown W. Odenthal D. The uses of telemedicine to improve asthma control.J Allergy Clin Immunol Pract. 2015; 3: 300-301Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar showed success in improving Asthma Control Test (ACT) scores and FEV% using TM among asthmatics during a 12-month period. However, it was not known how this compared with traditional in-person visits. Using TM, asthma control has been found to be not inferior to in-person visits in outpatient settings.4Portnoy J.M. Waller M. De Lurgio S. Dinakar C. Telemedicine is as effective as in-person visits for patients with asthma.Ann Allergy Asthma Immunol. 2016; 117: 241-245Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar,9Ozuah P.O. Reznik M. The role of telemedicine in the care of children in under-served communities.J Telemed Telecare. 2004; 10: 78-80Crossref PubMed Scopus (16) Google Scholar,10Reznik M. Sharif I. Ozuah P.O. Use of interactive videoconferencing to deliver asthma education to inner-city immigrants.J Telemed Telecare. 2004; 10: 118-120Crossref PubMed Scopus (18) Google Scholar TM also has demonstrated benefit in helping to improve proper administration of inhaled asthma medication and treatment adherence.11Chan D.S. Callahan C.W. Hatch-Pigott V.B. Lawless A. Proffitt H.L. Manning N.E. et al.Internet-based home monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year asthma in-home monitoring trial.Pediatrics. 2007; 119: 569-578Crossref PubMed Scopus (144) Google Scholar,12Trosini-Desert V. Lafoeste H. Regard L. Malrin R. Galarza-Jimenez M.A. Amarilla C.E. et al.A telemedicine intervention to ensure the correct usage of inhaler devices.Telemed J E Health. 2020; 26: 1336-1344Crossref Scopus (8) Google Scholar A meta-analysis did not show a negative effect of using real-time TM to improve asthma education in school-aged children.13Culmer N. Smith T. Stager C. Wright A. Burgess K. Johns S. et al.Telemedical asthma education and health care outcomes for school-age children: a systematic review.J Allergy Clin Immunol Pract. 2020; 8: 1908-1918Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Furthermore, a recent article of TM care delivered by an asthma specialist (allergist or pulmonologist) and a psychologist in an inner-city school demonstrated improvement in Composite Asthma Severity Index scores and medication adherence measured and reduced health care utilization via a Propeller Health web platform.3Lin N.Y. Ramsey R.R. Miller J.L. McDowell K.M. Zhang N. Hommel K. et al.Telehealth delivery of adherence and medication management system improves outcomes in inner-city children with asthma.Pediatr Pulmonol. 2020; 55: 858-865Crossref PubMed Scopus (35) Google Scholar Information and Communication Technology applications also have been helpful for the management of asthma using TM. These include use of internet-based platforms, use of e-mails and text messages, and video chats via computer or other electronic devices (eg, smartphones, tablets).14Cingi C. Yorgancioglu A. Cingi C.C. Oguzulgen K. Muluk N.B. Ulusoy S. et al.The "physician on call patient engagement trial" (POPET): measuring the impact of a mobile patient engagement application on health outcomes and quality of life in allergic rhinitis and asthma patients.Int Forum Allergy Rhinol. 2015; 5: 487-497Crossref PubMed Scopus (64) Google Scholar, 15Perron B.E. Taylor H.O. Glass J.E. Margerum-Leys J. Information and communication technologies in social work.Adv Soc Work. 2010; 11: 67-81Crossref PubMed Google Scholar, 16Poowuttikul P. Seth D. New concepts and technological resources in patient education and asthma self-management.Clin Rev Allergy Immunol. 2020; 59: 19-37Crossref PubMed Scopus (27) Google Scholar Online interactions between providers and patients can be helpful in managing a patient's asthma. One study conducted in Denmark using an internet-based interactive asthma monitoring tool resulted in improvement in asthma symptoms, medication adherence, pulmonary function, and airway hyperresponsiveness.17Rasmussen L.M. Phanareth K. Nolte H. Backer V. Internet-based monitoring of asthma: a long-term, randomized clinical study of 300 asthmatic subjects.J Allergy Clin Immunol. 2005; 115: 1137-1142Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar However, studies are still needed to show whether asthma telemonitoring with feedback from a health care professional is effective in decreasing the onset of exacerbations, visits to emergency department, or hospital stays.2Kew K.M. Cates C.J. Home telemonitoring and remote feedback between clinic visits for asthma.Cochrane Database Syst Rev. 2016; : CD011714PubMed Google Scholar The use of traditional instruments with new telemonitoring technologies can be instrumental for improving clinical outcomes. This is important, because traditional instruments for asthma care (eg, written asthma action plans) have shown variable clinical benefit.5Sheares B.J. Mellins R.B. Dimango E. Serebrisky D. Zhang Y. Bye M.R. et al.Do patients of subspecialist physicians benefit from written asthma action plans?.Am J Respir Crit Care Med. 2015; 191: 1374-1383Crossref PubMed Scopus (50) Google Scholar,7Toelle B.G. Ram F.S. Written individualised management plans for asthma in children and adults.Cochrane Database Syst Rev. 2004; : CD002171PubMed Google Scholar According to a 2016 AMA survey of practices that use TM by specialty, an average of 15% of practices in all specialties use TM for visits between providers and patients.18Kane C.K. Gillis K. The use of telemedicine by physicians: still the exception rather than the rule.Health Aff (Millwood). 2018; 37: 1923-1930Crossref PubMed Scopus (183) Google Scholar Although the use of TM has been shown to be effective for treating patients with asthma, only 6% of allergy practices used TM, making allergy/immunology the specialty with the lowest adoption rate of any of the surveyed specialties. Specialties with the highest use of TM were radiologists, primarily due to their use of asynchronous store and forward. Other specialties with high TM use included cardiologists who did a lot of RPM and psychiatrists who rely extensively on talk to manage patients. Allergists, who have traditionally relied on skin tests and allergen immunotherapy to manage patients, have not been as quick to adopt TM, though this is likely to change due to COVID-19. The pathway to creating a successful TM program should include a thorough understanding of the different telehealth options. Providers should ask themselves what their goals are. It should be clear how their asthmatic patients will benefit from these new programs. Also, patient goals need to be incorporated into the program. A successful program will adhere to state laws and ultimately must generate a strong return on investment. The use of TM has increased in part because COVID-19 has encouraged patients and providers to maintain social distancing that reduces the risk of infection. After all, as mentioned in a recent editorial, the only infection that can be transferred using TM is a computer virus.19Portnoy J. Waller M. Elliott T. Telemedicine in the era of COVID-19.J Allergy Clin Immunol Pract. 2020; 8: 1489-1491Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar Because of the increased need to use virtual visits for patient care, providers have needed to convert to a new technology quickly. To help with this process, we propose the following 10 rules for converting to TM. Several types of TM can be used to provide care for patients with asthma (Figure 1). Depending on the goals of treatment, these can consist of DTC, FVVs, RPM, communication via patient portals, m-Health, and use of E-consults. Each of these can be used to help patients with asthma depending on what is needed. It is important to choose a platform based on whether the visit needs to be synchronous or asynchronous, ongoing or intermittent, and monitored or patient-managed. During the pandemic, this has become the most commonly used type of TM. With DTC, the patient is located at an originating site (eg, personal residence, school, workplace) and the provider is located at a distant site (eg, hospital, office, provider's home). In a typical scenario, a provider located at his or her office connects to a patient who is located at his or her home using 2-way live video. The patient uses his or her own equipment making it possible for him or her to be seen at his or her home. Therefore, he or she needs to have a smart phone, tablet device, or computer with a video camera and a reliable internet connection. A physical examination using digital examination equipment is limited to whatever can be observed using the device that the patient has available. Although patients can report their current weight, height, pulse, and respiratory rate, this usually limits the examination to the skin and general impressions of respiratory distress. Blood pressure can be documented if the patient has a blood pressure cuff at home. An example of a physical examination that can be documented using limited equipment is shown in Table I. Such visits generally are limited to evaluation of established patients where a physical examination is not required. For an initial encounter, a limited physical examination can be performed and documented; however, the most common model when seeing a new patient is to bill the patient directly and not to use Current Procedural Terminology (CPT) codes. Some of these requirements have been relaxed during COVID-19; however, the waivers are likely to expire as the pandemic continues.Table IAn example of documentation of a physical examination that can be done using limited digital equipmentExamination:Vital signs: Weight-Height-Resp Rate-Pulse-General: No apparent distress. Awake, alert, well-appearing.HEENT: Normocephalic and atraumatic. Mucous membranes are moist. No periorbital edema. Facial muscles move symmetrically.Neck: Neck is symmetrical with trachea midline.Eyes: Conjunctiva and eyelids normal bilaterally. Pupils equal and round bilaterally.Sinuses: Patient/guardian was able to touch the face with no tenderness. No frontal or maxillary tenderness.Respiratory: Breathing unlabored, no tachypnea, no nasal flaring, no coughing, use of accessory muscles, chest retractions, unable to speak in complete sentences or prolonged expiratory phase.Cardiovascular: No edema, no pallor, no cyanosis.Abdomen: Nondistended.Skin: No concerning rash or lesions observed on exposed skin.Extremities: Normal range of motion observed. No peripheral edema.Neuro: Mood and behavior appropriate for age.Musculoskeletal: Symmetric and appropriate movements of extremities.HEENT, Head, ears, eyes, nose, and throat. Open table in a new tab HEENT, Head, ears, eyes, nose, and throat. Some patients do not have access to the necessary infrastructure (Wi-Fi, smartphone, etc.) for a DTC visit or they have a condition that requires a physical examination. For these patients, an FVV may be needed. To have this type of visit, the patient needs to travel to an accessible location that has digital equipment required to perform a physical examination. In addition to 2-way video equipment, FVVs also require the presence of a telefacilitator and digital examination equipment. The telefacilitator should be trained to operate the video equipment and to use diagnostic equipment so that the provider can properly evaluate the patient. Depending on the type of examination required, equipment may include digital stethoscope, blood pressure cuff, thermometer, scale, otoscope, ophthalmoscope, dermascope, or even ultrasound. This type of visit usually is done synchronously; however, an asynchronous visit for a physical examination to supplement a DTC video visit is also possible. RPM involves collecting personal medical data from an individual in one location and electronically transmitting that information to a provider or case worker at a distant site. It has been available in various forms for several decades and its use is now increasing with newer wearable technologies.20Greiwe J. Nyenhuis S.M. Wearable technology and how this can be implemented into clinical practice.Curr Allergy Asthma Rep. 2020; 20: 36Crossref PubMed Scopus (73) Google Scholar For asthma care, the information may also include home spirometry results, peak flow readings, and monitoring of asthma diaries. The results are forwarded to the asthma provider for interpretation followed by recommendations. Some key trends in RPM include monitoring the patient's temperature, oxygen saturation, pulmonary function, peak flow, blood pressure/glucose, and weight. Information obtained with a home spirometer is comparable with a standard benchtop-sized commercial spirometer for measuring parameters such as FEV1 and forced vital capacity.21Fung A.G. Tan L.D. Duong T.N. Schivo M. Littlefield L. Delplanque J.P. et al.Design and benchmark testing for open architecture reconfigurable mobile spirometer and exhaled breath monitor with GPS and data telemetry.Diagnostics (Basel). 2019; 9: 100Crossref Scopus (4) Google Scholar Once the diagnostic tools are identified, providers need to know about their availability/integration and interoperability and the ease of use for their patient population. Since 2018, Medicare has paid for RPM devices billed under the CPT code 99090. The benefits of using RPM include its convenience and the ability for ongoing continuous monitoring of patient response to treatment. The use of digital inhalers for real-time monitoring of inhaled medications has the potential to improve adherence and modify behavior by using real-time feedback. The devices use Bluetooth to connect to a smartphone app that stores usage data and can alert the user if any of the programmed parameters are outside of the recommended range. The 2 most studied devices are Propeller (Propeller Health) and the ProAir Digihaler (TEVA USA, Parsippany, NJ). The Digihaler is a digital inhaler with built-in sensors that can detect, record, and store information related to the use of the inhaler and measure inspiratory flow rates (L/min). The initial inhaler contained albuterol; however, another device with an inhaled corticosteroid (fluticasone) is also in development. Digital inhalers have been shown to improve medication adherence22Morton R.W. Elphick H.E. Rigby A.S. Daw W.J. King D.A. Smith L.J. et al.STAAR: a randomised controlled trial of electronic adherence monitoring with reminder alarms and feedback to improve clinical outcomes for children with asthma.Thorax. 2017; 72: 347-354Crossref PubMed Scopus (116) Google Scholar,23Mosnaim G. Li H. Martin M. Richardson D. Belice P.J. Avery E. et al.A tailored mobile health intervention to improve adherence and asthma control in minority adolescents.J Allergy Clin Immunol Pract. 2015; 3: 288-290.e1Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar and to improve asthma control or symptoms.24Merchant R.K. Inamdar R. Quade R.C. Effectiveness of population health management using the propeller health asthma platform: a randomized clinical trial.J Allergy Clin Immunol Pract. 2016; 4: 455-463Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar, 25Chan Y.Y. Wang P. Rogers L. Tignor N. Zweig M. Hershman S.G. et al.The Asthma Mobile Health Study, a large-scale clinical observational study using ResearchKit.Nat Biotechnol. 2017; 35: 354-362Crossref PubMed Scopus (156) Google Scholar, 26Zairina E. Abramson M.J. McDonald C.F. Li J. Dharmasiri T. Stewart K. et al.Telehealth to improve asthma control in pregnancy: a randomized controlled trial.Respirology. 2016; 21: 867-874Crossref PubMed Scopus (80) Google Scholar Reduced utilization due to asthma has also been reported.27Merchant R. Szefler S.J. Bender B.G. Tuffli M. Barrett M.A. Gondalia R. et al.Impact of a digital health intervention on asthma resource utilization.World Allergy Organ J. 2018; 11: 28Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar,28Zhou Y. Lu Y. Zhu H. Zhang Y. Li Y. Yu Q. Short-term effect of a smart nebulizing device on adherence to inhaled corticosteroid therapy in Asthma Predictive Index-positive wheezing children.Patient Prefer Adherence. 2018; 12: 861-868Crossref PubMed Scopus (11) Google Scholar If there was a "silver lining" to the COVID-19 pandemic, it is that providers and patients have become familiar with m-Health applications.6Stukus D.R. Farooqui N. Strothman K. Ryan K. Zhao S. Stevens J.H. et al.Real-world evaluation of a mobile health application in children with asthma.Ann Allergy Asthma Immunol. 2018; 120: 395-400.e1Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar m-Health involves the use of electronic devices to bring about a health change. This can range from patient self-management of asthma using an electronic diary to use of pollen count or air quality information that might trigger asthma symptoms. m-Health does not necessarily require active monitoring by a physician. It is most commonly used to reinforce patient education, provide medication reminders, and appointment reminders.10Reznik M. Sharif I. Ozuah P.O. Use of interactive videoconferencing to deliver asthma education to inner-city immigrants.J Telemed Telecare. 2004; 10: 118-120Crossref PubMed Scopus (18) Google Scholar In 2020, there were more than 400,000 health care apps available in the app stores; however, very few of them have been shown to accomplish a targeted goal.29Georgiou M. Developing a healthcare app in 2020: what do patients really want? 2020.https://www.imaginovation.net/blog/developing-a-mobile-health-app-what-patients-really-want/Date accessed: October 21, 2020Google Scholar Similarly, numerous types of electronic devices have been used to positively affect asthma outcomes but have not met specified objectives or have not been validated. In fact, apps are not regulated or approved by the Food and Drug Administration unless they are connected to a medical device for a specified purpose.30Himes B.E. Leszinsky L. Walsh R. Hepner H. Wu A.C. Mobile health and inhaler-based monitoring devices for asthma management.J Allergy Clin Immunol Pract. 2019; 7: 2535-2543Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar However, innovative mobile asthma applications continue to try to improve on traditional asthma resources such as asthma action plans and asthma diaries. Many apps that claim to improve asthma outcomes have not been reviewed or validated to ensure that they do indeed benefit patients with asthma. In 2013, a Cochrane review found insufficient evidence for the use of an app in routine asthma care.31Marcano Belisario J.S. Huckvale K. Greenfield G. Car J. Gunn L.H. Smartphone and tablet self-management apps for asthma.Cochrane Database Syst Rev. 2013; 11: CD010013PubMed Google Scholar One study evaluated an m-Health application that did not decrease emergency department visits, urgent care visits, or hospitalizations.6Stukus D.R. Farooqui N. Strothman K. Ryan K. Zhao S. Stevens J.H. et al.Real-world evaluation of a mobile health application in children with asthma.Ann Allergy Asthma Immunol. 2018; 120: 395-400.e1Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Another recent app, ASTHMAXcel, was found to improve asthma education as measured using the Asthma Knowledge Questionnaire. However, the authors concluded that although knowledge scores were increased, better knowledge scores were attained with the human-educator group.32Hsia B. Mowrey W. Keskin T. Wu S. Aita R. Kwak L. et al.Developing and pilot testing ASTHMAXcel, a mobile app for adults with asthma [published online ahead of print February 19, 2020].https://doi.org/10.1080/02770903.2020.1728770Google Scholar Despite this, the authors continue to improve on their app using patient engagement strategies, such as periodic updates and gamification for the pediatric population. Another app, the Scripps Asthma Coach, demonstrated improved ACT scores, decreased use of corticosteroids, and improved lung function.33Cook K.A. Modena B.D. Simon R.A. Improvement in asthma control using a minimally burdensome and proactive smartphone application.J Allergy Clin Immunol Pract. 2016; 4: 730-737.e1Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Many other apps have demonstrated improvement in different aspects of asthma care and potentially lowering the overall cost for asthma care.14Cingi C. Yorgancioglu A. Cingi C.C. Oguzulgen K. Muluk N.B. Ulusoy S. et al.The "physician on call patient engagement trial" (POPET): measuring the impact of a mobile patient engagement application on health outcomes and quality of life in allergic rhinitis and asthma patients.Int Forum Allergy Rhinol. 2015; 5: 487-497Crossref PubMed Scopus (64) Google Scholar,24Merchant R.K. Inamdar R. Quade R.C. 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A mobile telephone-based interactive self-care system improves asthma control.Eur Respir J. 2011; 37: 310-317Crossref PubMed Scopus (144) Google Scholar, 37Ryan D. Price D. Musgrave S.D. Malhotra S. Lee A.J. Ayansina D. et al.Clinical and cost effectiveness of mobile phone supported self-monitoring of asthma: multicentre randomised controlled trial.BMJ. 2012; 344: e1756Crossref PubMed Scopus (162) Google Scholar, 38Tinschert P. Jakob R. Barata F. Kramer J.N. Kowatsch T. The potential of mobile apps for improving asthma self-management: a review of publicly available and well-adopted asthma apps.JMIR Mhealth Uhealth. 2017; 5: e113Crossref PubMed Scopus (116) Google Scholar E-consults have been used successfully to avoid unnecessary or inappropriate consults and can lead to a more efficient use of a specialist's time. E-consults can also be a good source of referrals for asthma specialists. The University of California—San Francisco and San Francisco General Hospital were successful in reducing the numbers of consults in which specialists were unsure of the reason for consultations by almost 50% in medical specialty clinics, and by almost 75% in surgical specialty clinics.39Chen A.H. Kushel M.B. Grumbach K. Yee Jr., H.F. Practice profile. A safety-net system gains efficiencies through 'eReferrals' to specialists.Health Aff (Millwood). 2010; 29: 969-971Crossref PubMed Scopus (94) Google Scholar A service like this would tend to discourage services of low value and make proper use of the specialist's time. One study conducted at Massachusetts General Hospital found that most E-consults can be completed in approximately 10 minutes, and referring providers usually received recommendations within 1 day.40Phadke N.A. Wolfson A.R. Mancini C. Fu X. Goldstein S.A. Ngo J. et al.Electronic consultations in allergy/immunology.J Allergy Clin Immunol Pract. 2019; 7: 2594-2602Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar With the shortage of asthma specialists and the wait time for getting an appointment, E-consults are likely to become a very popular option. Patients can benefit significantly if community providers use E-consults to triage referral to allergists. Allergists are experts in conditions that require their expertise. As health care transitions to value-based reimbursement, asthma specialists will be incentivized to deliver care-based services that are not redundant or of low value. Specialists can encourage management of low-acuity asthmatics by the primary care provider with the use of E-consults. Because primary care providers can get an answer regarding the appropriateness of a referral in a timely manner, the relationship between the generalist and specialist can be further strengthened. During the COVID-19 pandemic, there have been almost daily changes in TM laws and regulations. As federal, state, and local regulatory laws and licensure requirements change, providers need to keep up to date. Organizations such as the National Telehealth Policy resource center can provide information regarding current laws and regulations for all 50 states and the District of Columbia.41Center for Connected Health Policy. Credentialing and privileging.https://www.cchpca.org/telehealth-policy/credentialing-and-privilegingDate: 2020Date accessed: June 30, 2020Google Scholar Other organizations such as the Joint Commission for Accreditation of Hospitals have agreed to allow hospitals that receive TM services to accept the credentialing and privilege status of providers who practice in another hospital.42Joint Commission on Accreditation of Healthcare OrganizationsFinal revisions to telemedicine standards.https://www.jointcommission.org/-/media/tjc/documents/standards/jc-requirements/revisions_telemedicine_standardspdf.pdf?db=web&hash=80DD5BCB3FE622C42BEE956C35611376Date: 2012Date accessed: July 6, 2020Google Scholar Furthermore, there is no requirement that TM be delineated as a separate privilege. Still, one should always check directly with the patient's health plan to determine its requirements for TM services. The Center for Medicare and Medicaid Services (CMS) has relaxed guidelines to allow the use of noncertified Health Insurance Portability and Accountability Act (HIPAA)-compliant telehealth tools. Permitted tools included HIPAA-compliant vendors (eg, Zoom for Health