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    Integrating telemedicine into your practice

    Virtual visits require physicians to establish telehealth guidelines

    Many primary care physicians worry that the rapidly-growing field of telemedicine is just too complicated and time-consuming to implement in their already busy practices. But physicians who have started offering telemedicine in their practices say there is no need to reinvent the wheel or spend a fortune to jump in on a trend that many believe will improve patient health.

    Telemedicine in primary care is used for a wide assortment of non-emergency problems for patients who want a doctor’s advice but don’t necessarily need to see him or her right away. Usually a phone call—although rapidly expanding to video conferences—telehealth doesn’t replace face-to-face encounters with physicians. Instead, it can augment the doctor/patient relationship.

    Telemedicine visits also help triage urgent requests to see a physician when the office is closed, mental health visits required for follow-up and prescription refills, follow up for diabetes, high cholesterol, hypertension and hyperthyroidism. Those visits may require pre-visit vital signs and blood work in advance of the telemedicine consult. Other visits may include lactation consultations for nursing mothers, group visits for diabetes and weight management, and well child exams.

    “Some form of telemedicine has existed in primary care for a long time,” says Jonathan Linkous, chief executive officer of the American Telemedicine Association.

    “What’s different is the change in technology and access to broadband that makes it more widely available to doctors and patients,” he adds.

    While technology is creating new tools, the government is encouraging improvements to better engage patients at lower costs.

    “We’re just at the tipping point,” Linkous says. “Patients already schedule appointments online, review their lab tests, email their doctors. They take photos of their rashes and email it to the medical office. Remember, most people rarely walk into a bank and deal with a teller these days because of ATM machines. Once patients get used to the new telemedicine system, they won’t go back to the old way of sitting in a waiting room for an hour for a routine problem.”

    telemedicine reimbursements by state

    Next: Getting started in telemedicine

     

    Getting started

    Getting started in telemedicine doesn’t have to require a huge outlay of money. “Almost every doctor has broadband access so the basic infrastructure is already in place,” Linkous explains. “Doctors will need to make a minor investment with a web camera and a secure portal tied into electronic medical records.

    “A web cam is a few hundred dollars,” he says. “But software systems need to be encrypted and HIPAA [Health Insurance Portability and Accountability Act]-compliant so that you can have secure video-conferences with patients. You want to be able to capture that information for electronic medical records. There are plenty of vendors that can help set up a secure portal and the basics of telemedicine.

    “The challenge is changing the mindset of your practice so patients can get access to their own records plus have access to you or your nurses,” says Linkous. “The hurdle is to integrate telemedicine into your practice: when to see patients, scheduling, guidelines for patients on how to use telemedicine.

    These are operational issues, not really technological ones,” he adds. “Doctors need to think about how to fit telemedicine into their daily schedules.”

    When it comes to licensing, state rules differ. Generally, a doctor must be licensed in the same state where the patient will fill a prescription. Malpractice insurance usually isn’t an issue, but physicians should inform their insurers of their plans. There could be an additional premium or some rider to the policy, he says.

    GlobalMed of Scottsdale, Arizona, is one of many companies that help physicians get started in telemedicine. It suggests that physicians draw up a plan and answer the following questions:

    • How do you expect the telemedicine program to tie into your regular in-person practice?
    • Are you planning to extend your practice and open satellite offices staffed by mid-level providers?
    • What type of clinic hours will you devote to telemedicine?
    • What time would you save by implementing telemedicine?

    GlobalMed recommends looking for systems that are intuitive and ready to go out of the box.

    Questions that should be addressed include:

    • Are there controls for hardware and/or software?
    • Does the location of the controls make sense and are they easy to use from the get-go?
    • How clear is the user manual?
    • How will your equipment arrive at your office? In pieces, with assembly required?

    Next: 5 legal challenges physicians face using telemedicine

     

    5 legal challenges of telemedicine

    Next: Reluctance to embrace telemedicine

     

    Reluctance to embrace telemedicine

    Internist/pediatrician Seth Eaton, MD, promotes telemedicine services for his Laurel, Maryland, practice of five doctors and three nurse practitioners by emphasizing the convenience of the service for busy patients who often don’t have time to come to the office.

    While telemedicine is now only a small part of Eaton’s practice, he expects it to grow significantly. “I liken it to Internet dating. Once considered rare and strange, it’s now commonly accepted. Some patients and doctors have been slow to accept telemedicine, but I believe it will enhance the reputations of practices while making life more convenient for both patients and doctors.”

    Eaton started using telemedicine less than a year ago and admits it’s been a slow go. “All eight providers are very busy and haven’t embraced the concept yet,” he says. “Neither have many patients. They’ve been reluctant to use it and prefer a face-to-face encounter. But these things take time.

    “A few years ago, no one knew what a patient portal was,” Eaton adds. “It was on the fringe. Now people accept it. I think telemedicine will reach the same arc over the next few years.”

    Eaton uses telemedicine for a variety of purposes, such as for mental health follow-ups for patients who started using an anti-depressant to see how it’s working;  urgent care visits, and management of chronic conditions. He also sees patients possibly in need of urgent care services such as rashes or allergic reactions.

    Another significant area where telemedicine can help, Eaton says, is in basic management of chronic conditions such as hypertension and diabetes. Patients can speak with providers about their blood pressure targets without losing time from work, and patients with diabetes can talk to a provider about managing their condition or even join group visits for education and support.

    A national Scale

    Compare that effort to Teladoc, the nation’s largest telehealth provider that has more than 7.5 million members and will complete more than 200,000 consultations this year.

    “Employers are embracing the model as an integral part of their benefits while seeking to maximize patient access, quality and affordability,” says Chief Executive Officer Jason Gorevic. “Teladoc connects patients with a board-certified, state-licensed physician in an average of 16 minutes.”

    A Teladoc consultation costs patients $40 per visit. Its doctors are independent contractors who receive a portion of that fee.

    “Some insurers pay, some don’t,” Gorevic says. “Many patients pay it out of pocket for the convenience and service,” he says. “Some doctors are semi-retired or seeking to supplement income. Patients create an online account with their medical histories so the consulting doctor can review their records electronically before speaking to the patient.”

    The company works with physicians who would rather incorporate telemedicine into their practice. “We’ll provide the software, help set up a web site and portal, scheduling, etc. We help facilitate payment from insurers and employers as well,” Gorevic says.

    Teladoc has more than 100 clinical guidelines and does quality assurance review each month. The company also covers its physicians for malpractice.

    “Physicians don’t have to adhere to the guidelines, but they must document the reasons they chose not to,” Gorevic says.

    A recent RAND Corporation study found that patients who use Teladoc are less likely to require follow-up consults, with only 6%  doing so compared to 13% who visited an office, and 20%  who visited an emergency room. RAND also found telehealth services to be an entry point to the healthcare system for people who have difficulty accessing their regular physician, including employees who were unable to take time off work.

    Timothy Howard, MD, spent 20 years in his family medicine practice in Huntsville, Alabama, before joining Teladoc full time.

    “I have the patient’s electronic medical record in front of me with his history, adverse events and previous consults,” Howard says. “It’s just like taking a call in my regular practice but with better information. Also, we didn’t get paid for taking calls. Now I do.”

    Howard is licensed in multiple states in order to comply with laws that require  doctors to be licensed in the state where he or she prescribes. “With the economic downturn, patients have huge deductibles and can’t afford to get to a private office.”

    Most consults are by telephone, although videoconferencing is growing, he says. The fee is $40. Some companies only charge $10, while others underwrite the entire cost.

    Many patients use the service as an inexpensive second opinion. “I had a patient call because his physician recommended that he have hernia surgery,” Howard says. “He explained his symptoms to me, and I agreed that he should see a surgeon. It was reassuring to the patient to have that backup.”

    Next: A 24/7 virtual clinic

     

    A 24/7 virtual clinic

    On a smaller scale, Seattle-based Carena Medical Providers devotes its practice exclusively to telemedicine. It has relationships with some large health systems to augment its own primary care practices.

    “We operate a 24/7 virtual clinic where medical care is delivered by phone and webcam to treat dozens of common issues,” says Ben Green, MD, Carena’s medical director.

    Carena has five physicians and 10 nurse-practitioners. “When we started in 2010, the vast majority of consults were by telephone. Patients weren’t confident about webcams. But in a few years, the majority of consults will be videoconferencing,” he says.

    About one-quarter of the consults result in a referral to the emergency department, a specialist or the patient’s primary care doctor, he says.

    “Patients often call when they injure themselves,” Green says. “Via webcam, we can look at the laceration and manage it. In other situations, we direct patients to the right facility, often urgent care which is a lot less expensive than the emergency room.”

    The consult costs patients $35 per visit and most pay by credit card. “Insurance payment varies by state but this is cheap enough that many patients don’t bother trying to get reimbursed,” he says.

    Physicians should check with their liability insurers before instituting a telemedicine service even though lawsuits are few and there’s rarely an extra premium. “We’ve been in business since 2002 without a single lawsuit,” says Teladoc’s Gorevic. Physicians also need to make sure their systems are secure and HIPAA compliant, he says.

    “Providers have been doing on-call services forever,” Green says. “It’s a competency every doctor can do. But with telemedicine, it’s a different mindset. Does the patient need to be seen the next day? Most often, he doesn’t.

    “We’re providing high-quality, safe care for them. And we get compensated for it. As the field grows, providers will embrace it because more patients will expect and demand it.”

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    • deansrv72@------.com
      While the article has some useful info, let's be fair...and clear... nurse practitioners and physician assistants are by no means 'mid-level' providers. That would only be to suggest mid-level care. And lest we not forget that the term mid-level was derived by physicians to help delineate their title, and power, within the ever-changing healthcare system. NPs and PAs deliver excellent, and well-established care (and outcomes), and will only be gaining popularity and strength in the not so far off future.
    • Dr. jordan
      Telemedicine is coming..no doubt about it. I have been vexed by two things...one is the historic presumption that no news is good news when a patient leaves the office, but in truth, no news is just no news. Good news is good news. Furthermore, how can doctors expect to get more information without more time to process this and what are the mechanisms to get paid...and how are they audited, and how are they not gamed. My project, Healthloop, attempts to solve these issues by creating structured, exception based feedback loops within the context of a diagnosis and treatment. The future of telemedicine may include video visits, but they still require two people to be present at the exact same time...and as any doctor will tell you, our schedules are hard to keep when patients present with problems that are not cut and dried (in 15 minutes). Asynchronous, mobile solutions are going to be the killer app in telemedicine...methinks. Jordan L. Shlain MD

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