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Setting Up a Telemedicine Program in Your Practice
Glossary
 

Welcome! This article is part of a Medscape Physician Business Academy course, . Visit the Course Page to take the full course and receive a certificate.

Introduction

Getting started with telemedicine can be accomplished with a modest commitment that does not have to disrupt your practice. Then, once you have established a telemedicine program, you can build on your initial services and create more sophisticated offerings.

A Step-by-Step Checklist to Launch Your Program

The following is a checklist of the steps you need to take when starting a telemedicine program. The rest of this chapter will provide more detail on a few of these steps.

Have a plan. Ask yourself: What do you want to accomplish with telemedicine? It may be to make yourself more accessible—for example, freeing up your schedule for in-person visits, or using telemedicine in off-hours. Or you may want to add new patients, such as millennials who are more comfortable with the technology. This thought process will help you decide who will be your telemedicine patients and what kinds of services to offer them.

Select a form of telemedicine. Audio-video services are more likely to be covered by payers, but asynchronous telemedicine can be a better medium for dermatology cases, parents' simple questions for a pediatrician, or as an adjunct to audiovisual visits. An asynchronous system is also easier on doctors' schedules. Physicians are then able to deal with messages on their own time, but patients should still know how long it will take to get a response.

Ask your patients. Make sure patients are really open to televisits. Would they be comfortable with them if it meant less waiting? And if so, which services would they be interested in? You may simply ask patients, or give them a questionnaire to fill out.

Involve your staff. Ask staff to foresee any logistical problems, such as potential problems incorporating televisits with in-person scheduling. Also, if your staff is involved in planning from the start, they are more likely to support the process and make sure snafus don't occur.

Learn about coverage. Contact your payers to determine what telemedicine services will be reimbursed. As explained in Chapter 4, commercial insurers and Medicaid often cover video telemedicine, but there are some exceptions, so it's very wise to find out in advance. For example, Medicare and some Medicaid programs require patients to come into a facility.

Decide how you will use telemedicine. Will you use telemedicine to offer same-day appointments, after-hours care, or visits determined by the doctor? You might decide that at the end of certain in-person visits, you will recommend telemedicine for the next visit to particular patients.

Know the regulations. As discussed in Chapter 3, state regulations may limit the mode of telemedicine, location of patients, and whether you need to have a preexisting relationship with the patient in order to prescribe. You may also need to provide for informed consent, and you will always have to be licensed in the patient's state. Many of these rules, however, won't be a problem if you limit services to existing patients in your own practice.

Make sure patients are aware that you offer telemedicine. You can put up signage in your practice and post articles on your website, and you and your staff can bring it up with patients during in-person visits. Explain the advantages of telemedicine and how it works.

Start with just a few services. Begin telemedicine by limiting it to simple services that could draw a lot of patients. For example, primary care physicians might use it for providing medication refills, blood pressure follow-ups, or diabetes check-ins. Surgeons might use it for preoperative or postoperative visits for certain procedures.

Choose telemedicine software. This was covered in Chapter 4. Choose a brand that makes it easy for patients to sign up. The fewer steps patients have to take, the more likely things will run smoothly. The simplest way is for patients to enter through the practice's patient portal and pick a time. If possible, speak with other physicians who offer telemedicine and ask about their experiences.

Integrate with scheduling. To prevent misunderstandings by staff, make sure your telemedicine visits appear on the practice's schedule. Telemedicine software through electronic health record (EHR) systems often integrates into your schedule, whereas self-standing software may be separate, requiring manual entries into the schedule.

Keep technology simple. The simplest setup for audiovisual telemedicine is a computer with a camera that links up to your software. But even at the start, consider purchasing a headset with microphone, which can plug into your computer. This will provide better audio. There are also privacy issues that will be discussed later in this chapter.

Set up your space. Find a quiet room in your practice—preferably with a door that can be shut, so that people are not coming and going, violating your telemedicine patient's privacy. Also, make sure the room has adequate lighting so patients can see the person whom they are speaking with.

Perform some trial runs. Once you have the technology and the space set up, try out a telemedicine visit with staff or someone else who can give you feedback. In this way, you can learn to deal with any technological problems and develop an engaging demeanor for the patient.

Do You Need to Hire a Consultant?

For many people, hiring a consultant to start offering telemedicine is not necessary. State regulations can be complicated, but compliance is feasible if you focus on one or two states. There are ample resources on this, which are listed below.

Setting up the technology may seem daunting, but it is really quite easy for a simple offering, such as audiovisual services for patients in their homes. This was covered in Chapter 4. Doctors who are worried about having to deal with technical problems can buy the more expensive platforms that cover 24/7 customer support.

Doctors who graduate to more complicated functions, such as telemedicine in a healthcare facility, often partner with a hospital to do this. If you are doing so on your own, you can contact one of the telemedicine consultants who work with hospitals.

Resources

Center for Connected Health Policy. A nonprofit agency that provides educational material for telemedicine. Call or email to ask about general telehealth policy issues. For more in-depth questions, CCHP provides consultative services.

Telehealth Technology Assessment Resource Center. This federally funded agency will answer such questions as what equipment you will need to buy, what your initial program services will be, and how to grow services.

A regional telehealth resource center. There are 12 centers covering different regions of the country. They provide technical assistance, training, and other support. For example, the Mid-Atlantic Telehealth Resource Center offers free consultations several times a month and sponsors an annual summit providing education on telemedicine topics. It also provides a list of consultants in particular telemedicine topics.

Center for Telehealth and eHealth Law. A nonprofit agency that provides information on such topics as physician licensure, credentialing and privileging, and reimbursement policies.

Meetings and summits. Find out about upcoming meetings and summits on telemedicine.

Telehealth Compliance Checklist. This brief checklist, provided by one of the leading telemedicine law firms, contains the essential legal and regulatory issues that you need to know.

Setting Up Your Space

In the telemedicine visit, you should be sitting at a desk or table, with the camera placed at eye level in front of you. Clear the desk's surface of objects. Consider installing a screen behind you to block off distractions. There are collapsible screens you can buy that fit on the back of a chair.

Wearing headphones protects privacy so that the patient's voice is not heard, and it also makes it easier to hear heart sounds when a stethoscope is used at the patient's end. In many cases, you'll need two computer screens: one for the telemedicine image and another to enter notes into your EHR system.

The existing lighting in the room may have to be supplemented with extra fluorescent fixtures that help evenly distribute the light. The color of the walls may impair the quality of the video image. Light blue is a good background color, and again, a screen can assist with a clean video image.

Presenting Yourself

Dress the part. Even if you're working from home, dress as you do when you see patients in the office. Be aware that excessively bright or dark colors, pinstripes, checks, or other complex patterns will create distracting patterns on the screen.

To develop a good "webside manner" with telemedicine patients, you need to feel comfortable with your video presence. Before you start seeing patients, put the video in record mode and rehearse in front of the camera. Then see how you come across. It may take many rehearsals before you feel at ease with your appearance.

Be punctual for tele-appointments. Many platforms allow you to set up a notification system that lets patients know when you're ready, and lets you know when patients are ready.

Be inviting. Nod every so often when patients are speaking, and ask questions to encourage them to open up. Maintain eye contact with patients. Rather than looking at the image of patient on the screen, look into the camera lens. When you have to look away to consult the record or write orders, let them know. Because telemedicine interactions are more limited than in-person ones, be attuned to visual cues from the patient.

The Content of the Visit

Prepare for the visit by reading the patient's complaint and having the patient's chart ready. Confirm the patient's identity, take a history, and assess the patient's appearance. Determine whether the patient would be better off with an in-person visit.

Many of your questions are basically the same as those you would ask during an in-person visit. You will need to get the chief complaint, a history of the present illness, associated signs and symptoms, past medical history, family history, and personal and social history, and review medications, allergies, and detailed symptoms.

You may have to direct the patient to perform a self-examination. This may require asking the patient to walk or stand or bend, move a limb in a certain way, and test range of motion or power. Unless you have mobile medical devices or a telepresenter on-site with the patient, you will have to rely more on what patients are telling you than in an in-person visit.

Collecting Payments From Patients

Because the telemedicine patient does not see you in person, the practice needs to create a method to collect the copay and other out-of-pocket payments from patients.

Billing for the visit should be discussed before the telemedicine visit. Patients should understand the amount that will be charged, what they will have to pay, and the procedures for payment.

There are several ways to collect the copay and other out-of-pocket payments, depending on the platform you are using. For example:

  • You can resolve payment when patients schedule their appointments. Patients can provide their credit card information, and the practice finalizes payment after the visit.

  • The platform may not provide for electronic payment. In this case, staff are alerted when patients request an appointment, and staff then contact the patient to confirm insurance and collect the out-of-pocket charge.

Advanced Use

More advanced use of telemedicine includes setting up an office for patients to visit, so that the doctor can conduct a more extensive examination.

Specialists often make these arrangements with hospitals that can't provide their services in-house. They can also be made by large, multisite practices or by physicians who have telemedicine contracts with nursing homes or schools.

This arrangement requires building a telemedicine cart at the patient's end, and designating a nurse or other clinician—the telepresenter—to help the patient with the physical examination.

The telemedicine cart might consist of a pan-tilt-zoom video camera and mobile medical devices, such as a digital stethoscope, an ophthalmologic scope, and various other scopes, depending on the case. This equipment can be assembled or bought as a complete product. The cost can range from thousands to tens of thousands of dollars.

Conclusion

Telemedicine can be a useful tool for practices. The convenience it affords patients can help you retain current patients and attract new ones. Practices can use it to provide follow-up visits, reinforce treatment adherence, and offer specialty services in underserved areas.

Originally envisioned for use in rural areas, telemedicine is now being used extensively by hospital systems, large group practices, and online telemedicine services. Small practices have shied away from it, but it is disarmingly easy for them to use. Telemedicine is already widely used in such specialties as pediatrics and behavioral health, but it can also help specialties with low adoption rates, such as surgery.

Extensive regulations and licensure requirements have held back growth, but regulations are not hard to follow if you keep to one state. Currently, malpractice is not a high risk, but it could become one as telemedicine gets more popular.

The technology for telemedicine basically amounts to using secure software, which creates the telemedicine connection. Regarding reimbursement, regular Medicare is generally a scanty payer, but Medicare Advantage, Medicaid, and private insurers pay quite well.

Planning for telemedicine requires determining whether your patients will actually use it, deciding how you want to use it, and integrating it into your practice. You can start with one or two services, such as follow-up visits or refills, and expand from there.

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Welcome! This article is part of a Medscape Physician Business Academy course, . Visit the Course Page to take the full course and receive a certificate.

 
| January 01, 2019