Optimizing telehealth pain care after COVID-19

Abstract

“If you have ever thought of doing telehealth, now's the time to get started.” —Peter McGough, MD (Medical director of the University of Washington neighborhood clinics: KUOW/National Public Radio, 2020.) 1. Introduction The COVID-19 pandemic has presented major challenges to pain care, as pain clinicians face severe restrictions in their ability to provide usual in-person assessments and treatments. COVID-19 has also exposed prepandemic problems in providing comprehensive pain care. Yet, despite this crisis, there have been encouraging developments for long-term delivery of pain services, most notably the explosive growth in the adoption of telehealth technology and clinical resourcefulness in its applications. Furthermore, the size and urgency of the COVID-19 pandemic has seen many cumbersome local, regional, and national health policy rules regarding the access, delivery, and reimbursement of telehealth temporarily waived. These changes have afforded an opportunity to develop new ways of operating and a glimpse of how life could be for pain services under a “new normal.”81 Importantly, telehealth has the potential to transform pain management, particularly for those with complex pain care needs living remotely from pain facilities or in low-resource settings, removing barriers to multidisciplinary pain management delivered in a collaborative, interdisciplinary way—the optimal treatment approach for chronic pain.21 Pain researchers have provided timely reports of the available evidence for treatment modalities capable of being delivered remotely.25,81 However, the provision of pain services at local, regional, and national levels entails more than a consideration of evidence for individual service components. A broader framework is needed. This topical review considers the value case for telehealth-based multidisciplinary pain management approaches, reviews available evidence, delineates obstacles, and proposes solutions across the domains of health systems, public health, and reimbursement policies. We should not turn back; rather, we should advance the potential gains of telehealth pain services. At the same time, it is imperative that we implement a research agenda evaluating outcomes, costs, and acceptability alongside these new clinical developments. 2. What is telehealth? Telehealth is expansively defined as the use of technology (electronic information and telecommunication) to facilitate long-distance health care, health-related education, public health, and health administration.11,45 Available methods for the delivery of technology-enabled care currently include synchronous (eg, live videoconferencing), asynchronous (eg, store-and-forward transmission of photographs, images, vital signs, and video clips for later review), mobile health (M-Health) (eg, remote patient monitoring and patient-reported outcomes), and electronic health (E-Health) (eg, live or recorded educational presentations to geographically disparate groups of patients or healthcare professionals). Each method has the potential to fill specific gaps in pain management, offering unique promise for chronic pain management. In addition to research opportunities, these developments present important training imperatives as well. 2.1. Pain medicine by telehealth Despite strong support for the value of telehealth across a range of medical disciplines and methodologies,7,13,16,29,30,52,55,61,79,88,93 recent recommendations for pain management during the COVID-19 crisis have identified only a time-limited role for synchronous delivery of telehealth care.19 Based on telehealth's demonstrated ability to improve access, collect and interpret health data, and provide educational consultative support for care by multiple medical disciplines, and considering the recent surge in implementation, there may be a case for a more permanent response beyond COVID-19. Pain medicine clinicians can interview, observe, and counsel patients with chronic pain through audiovisual technologies. However, performing the physical examination remotely remains a vexing challenge. This is a crucial portion of accurate and thorough diagnostic evaluation of patients with chronic pain, needing to touch, press, palpate, and move patients. This challenge can be overcome, in part, by the presence of an on-site medical clinician seeking consultation, or with less easily accomplished instructional coaching by an attendant caregiver, but these may not always be available.93 Telehealth peripherals (eg, electronic stethoscopes, teleophthalmoscopes, and video-otoscopes93) are common assessment tools for remotely delivered primary health care. Pain assessment questionnaires, an established component of pain assessment,14 are similarly M-Health peripherals that we have successfully introduced before the telehealth visit through premailed, electronic health record (EHR) “patient portal”97 or mobile devices.76 A promising alternative to new patient assessment under COVID-19 restrictions has been trialed at our pain clinic (University of Washington [UW]). Medical providers conduct a familiarization telehealth interview to hear the patient history, collect identified additional treatment records, initiate pain neuroscience education, and set treatment expectations in preparation for that patient's future in-person visit which is then scheduled by priority. This approach offers potential to begin a therapeutic relationship in advance of their future visit. Follow-up visits can be conducted virtually, assuming no newly presenting pain problem, because established patients rarely require a hands-on physical examination. Patient history, review of systems (sent through our patient portal), and medications can be reconciled, and nondrug treatments reviewed. Difficulties with and adherence to treatments are discussed, laboratory and imaging studies reviewed, and if controlled substances are prescribed, the state's prescription drug monitoring program can be queried. Urine drug testing, if necessary, can be performed at patients' primary care site. Prescriptions can be electronically refilled, including controlled substances using “E-prescribing” dual authentication technology.33,54 When a new or exacerbated pain problem is identified, we ask patients to touch locations of musculoskeletal and/or visceral pain and directly visualize the skin and presence of edema. Movement can also be evaluated visually by telehealth by observing ability to sit-stand and heel-toe walk and query if pain is experienced during demonstrated range of motion of the extremities and spine. For established patients, we are able to identify whether they are at known baseline, or whether any new or worrisome findings are present. Electronic consultations (E-consult), provider-to-provider communications within a shared EHR, have been introduced in larger health systems to improve access, convenience, timeliness, and costs of specialty care18,90 and seem best suited to support the primary care management of chronic diseases. Widespread implementation has been challenging, requiring significant institutional investment, leadership, and clinician incentives.89 Because E-consultations are intended to serve as an alternative to comprehensive consultation, straightforward conditions and generalizable recommendations are most suitable (eg, drug dosages and diagnostic tests that may be appropriate). As such, successful deployment is described in those medical specialties with well-defined assessment and treatment pathways (eg, endocrinology, dermatology, and neurology). For example, an E-consult regarding a focal nerve impingement may support a potential role for a selective pain interventional procedure or assist preoperative medication management before elective surgery or postoperative opioid tapering. An E-consult may also help guide clinical decision-making for primary care providers when measures of widespread pain and symptom severity scores support a diagnosis of nociplastic pain (“central sensitization”). Pain medication dosing, drug–drug interactions, and adherence to opioid treatment guidelines and rules are other examples of potentially successful roles for E-consultation in chronic pain. For patients with more complex chronic pain conditions, especially those who may require multidisciplinary pain management, E-consults may yet prove effective.48,82 If a physical examination is indicated, a primary care provider's physical examination of a complex chronic pain condition is of value but not a substitute for one performed by a pain-trained physician. Use of EHRs has proved useful for identifying patients with substance use disorder who seek opioids frequently and improperly from the emergency department (ED) with complaints of pain. In 2008, the ED Information Exchange system was introduced and subsequently deployed at all 90 EDs throughout Washington State, enabling the coordination of patient-specific multidisciplinary care plans for frequent ED users identified across the state. With direct connectivity to the state's prescription drug monitoring system, ED providers access details of a patient's statewide dispensed opioid prescriptions (eg, quantity, last fill dates, and prescribing providers) and ED Information Exchange reports on previous opioid overdose diagnoses. This telehealth approach to ED pain management also includes a coordinated care plan for the management of pain, which has demonstrated improved safety, provider satisfaction, and reduced costs.68 2.2. Behavioral health pain management by telehealth Behavioral health (BH) interventions are an integral aspect of multidisciplinary pain treatment.32,51 Of these interventions, cognitive-behavioral therapy (CBT)-based techniques are most common and widely supported for chronic pain management26,94 and are intended to augment patients' nonpharmacological pain-coping strategies. Cognitive-behavioral therapy techniques include stress management (eg, diaphragmatic breathing and muscle relaxation), identifying and modifying unhelpful thoughts about pain, strategies for paced/gradual upgrading of physical activity to reduce pain flares and increase activity consistency, goal setting and structuring of daily routines to maintain behavioral activation, addressing comorbid problems with insomnia, and effective communication strategies around pain-related difficulties.71,86 As with in-person treatment, CBT approaches are the most commonly used BH interventions by telehealth15,26 and generally demonstrate comparable efficacy to in-person treatment.15 Previous meta-analytic reviews have indicated small but statistically significant effects of CBT approaches for reducing pain, pain-related activity interference or disability, and mood disturbance, both for in-person treatment94 and Internet-based platforms.26,66 Emerging evidence indicates BH approaches may facilitate reduced opioid use for chronic noncancer pain.27 To date, few studies have determined differences in treatment acceptability and satisfaction between Internet and in-person treatment,26 although greater attrition rates in some Internet-based interventions have been reported.15,46 In Internet-based interventions, lack of engagement with the therapy team may be improved with individual videoconferencing rather than self-directed Internet-only intervention,66 a question for future research. 2.3. Physical therapy pain management by telehealth Like traditional in-person care, telehealth by physical therapists involves patient-centered information exchange, examination, and multimodal interventions. The approach may be synchronous or asynchronous and blended with in-person care or performed by itself.60 Although the evidence based on telehealth interventions provided by physical therapists is limited, early evidence suggests there is potential for effective and high-value care.41,50 Best practices, most effective components, cost-effectiveness, and heterogeneity of the treatment effect for subgroups or chronic pain conditions still need to be established. Numerous pilot trials or in-progress clinical trials on this topic indicate more evidence is imminent.35,39,56,58,69 Systematic reviews show that pain neuroscience education has small effects on pain intensity and function but more clinically meaningful impacts on fear and pain catastrophizing.92,95 Effectively addressing patients' beliefs about pain necessitates consistency in language and terminology used by medical providers and physical therapists.64 Telehealth interventions may facilitate this consistency. Exercise is consistently associated with reduced pain and disability for multiple chronic pain conditions,34,42,80 and similar outcomes may be achieved through telehealth delivery.1 Psychologically informed physical therapy incorporating behavioral strategies may augment these effects43 and has been delivered by telephone or electronic methods in trials.3,9,10,73 Optimal methods for delivering telehealth interventions are unclear, but physical therapists may prefer videoconferencing to observe patients' movement. Depending on patients' circumstances, community-based physical activity or mind–body practices, such as yoga and Tai Chi, can be incorporated within a pain management program in addition to, or instead of, exercise.80 Several M-Health platforms and applications have been designed to facilitate and provide exercise and mind–body practices. The challenge for telehealth will be to successfully integrate physical activity or mind–body practices, medical, behavioral, and physical therapies, to replicate in-person multidisciplinary pain management.51 2.4. Pharmacy pain care by telehealth Clinical pharmacists perform pain management roles in both and care the of the COVID-19 crisis, their role has been across a larger range of telehealth At our a pain management telehealth was in with health to directly primary care through an are by a pain management supported by a pain medicine when needed. about medication therapy of pain management and/or regarding opioid In response to COVID-19 rules regarding controlled substance pain medications have been These changes have the on and patients, such as to prescriptions in-person evaluation and the time from the of emergency prescription to when a the controlled substance for emergency prescriptions to be or in of a prescription if to the of controlled substances has been available in the for a but this was only used despite directly to the is an important to reduce patient in-person within healthcare and has been to improve medication in Although the COVID-19 crisis has its implementation, the and of still evaluation education, and policy agenda for multidisciplinary pain management. barriers and of implementation and access to multidisciplinary pain care delivered by in access to multidisciplinary pain care. and use of to access for pain-related clinical and pain consultations for and for optimal access to and use of pain care. and reimbursement for all across a and specific and that barriers to telehealth care (eg, requiring visits or and of access to in and access to and in and telehealth reimbursement for telehealth and in-person maintain for telephone and provider and clinical for the provision of telehealth care. Patient for telehealth services across and and when directly the patient of video for telephone evaluation and management services. Patient to care, by electronic or in national regarding for pain providers and of for telehealth services. for (eg, health and associated with use of telehealth for multidisciplinary pain adherence to national guidelines (eg, opioid prescribing and associated with pain care. and implement educational for and providers to patient and of patient and maintain that will patients patient to use or of health the of multidisciplinary pain management on patient-reported outcomes (eg, pain and of and healthcare with in-person optimal telehealth and of costs and of multidisciplinary pain care with in-person pain care. and in pain management delivery by and training for and providers in the for pain telehealth technology and remote care training in and health across health telehealth regarding reimbursement for coordinated multidisciplinary care and provider all healthcare providers to conduct and for care through telehealth when clinically and by telehealth and pharmacists as services that improve Internet-based patient Use a approach to of care through groups of patients, and satisfaction and engagement with multidisciplinary pain care delivered by telehealth for patients, and healthcare and educational (eg, and case that care. reimbursement to facilitate team synchronous and asynchronous and high-value multidisciplinary pain for of care of multidisciplinary pain care delivered by multidisciplinary telehealth pain management A aspect of effective multidisciplinary care involves coordination of services by by the When treatment providers are not it remains that providers have and but this is not to the COVID-19 and it is to be a the pandemic challenges then and With the of there have been for the adoption of telehealth Despite in telehealth and costs, challenges in of of and and electronic medical record Internet access and also a especially in and of lack access to with of Furthermore, Internet access in is more and the and of connectivity for These challenges are despite similar of of Internet technology are across most during COVID-19 has systems, and usual Telehealth that the patient at patient access and access to with and at telehealth at a of and in using the show a to and to the need for additional preparation of and technology access will be for implementation of the new telehealth but currently available communication remains suited as the of care for straightforward patient such as medication and for laboratory and imaging the use of technology in delivering multidisciplinary pain management between the patient and clinicians is more complex and will require that a between for clinical time for the clinicians when levels of telehealth and and between the and in such as the and have with a provision of telehealth the use of a range of any or video technology such as and and are both temporarily However, access to video for at services, when may be on the of of access to services and for telehealth services and complex before but it is also that have been telephone of telehealth for many and they provide useful for those that have to this of care the best examples can be in and the However, these also have national health service systems by their of access for patients is A in such as the and of access in primary and care is provided on a or has been a across health restrictions in many reimbursement for services for and by provider and clinical patients in and telehealth visits directly the patient including telephone the COVID-19 many of these restrictions have been to patients' to the The for example, that newly are in and have no to or COVID-19. However, in both the and there are for these important for the future of how the COVID-19 emergency will and which of the and will be or evidence suggests that are of and to telehealth systems and services that may not be or the pandemic has it is imperative that those in providing telehealth-based pain management, directly or will need to their value and Patient and satisfaction with telehealth The of long-term telehealth-based pain management will also on patient engagement in and satisfaction with As there is evidence that patients who are less in telehealth may be more to and many that are by systems have from adherence and Previous studies of patient in medical systems to pain management services also common of including a lack of coordination in from providers or and barriers including or access to services or to and from treatment Effectively patient engagement necessitates communication between providers and patients, and their significant such as or that treatment plans are to of the clinical and or are identified and in a timely In many multidisciplinary treatment these communications have been by or care or pain management will from the of these same pain care through education, and policy The COVID-19 pandemic a unique opportunity to develop telehealth as a of providing and multidisciplinary pain care. To this in we education, and policy to of multidisciplinary pain care. of these are as on of barriers and to the implementation of telehealth technology and coordinated interdisciplinary care at the and system levels have the potential to improve the and of For example, education on and policy on and electronic for telehealth Furthermore, the COVID-19 pandemic has to clinical training and the need for and provision of to access for pain-related clinical and pain consultations for and For example, the that pain education delivered by a of multidisciplinary pain to gaps in training and patient case presentations to provide for to COVID-19 pain care restrictions by a with for providers to support their care of patients with complex chronic pain. Furthermore, at all levels and in-person clinical have this education and education patient and during multidisciplinary pain care will be an important the lack of opportunity for hands-on physical and electronic of health the and of will be important for the widespread adoption of telehealth for pain management. Furthermore, a evaluation of adherence to national guidelines and rules that assessment (eg, for opioid for comorbid conditions (eg, and stress and prescribing (eg, prescription drug monitoring and prescriptions for chronic are being conducted in the of telehealth review and of and especially in of could serve to maintain patient A crucial in the broader use of telehealth is to the of multidisciplinary pain care with in-person pain As with in-person pain management, patient assessment include not only pain reports but broader as (eg, pain and to facilitate and treatment M-Health technology (eg, at and electronic for more can be incorporated the telehealth clinical to these outcomes (eg, and mobile can also be used to changes in physical activity and specific telehealth and the optimal and of multidisciplinary pain care can be determined to patient and it will be to conduct studies to of multidisciplinary pain care in the and to improve outcomes may include use and engagement in provider-to-provider such as for and which to support providers a The value of pain management is supported by with of provider and/or improved communication between patients and greater and to specialty clinic changes (eg, and clinic that increase the of in may be approach for providing training and of informed methods for providers to pain by patients with chronic pain involves with between in (eg, chronic pain and activity to a is can be conducted in small groups or in-person with larger The use of a approach the to that a of is achieved by the for of multidisciplinary care delivered by telehealth will need to be established. 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