Michael Tracy, MD, received an urgent phone call from a patient who had cut his hand and was bleeding; his patient wanted to know if he should visit Tracy’s office or go straight to the emergency department.
Tracy, a primary care physician in Powell, Wyo., was working to quickly get information about the injury when the patient suggested they use their iPhone’s FaceTime function so Tracy could see the cut for himself. Tracy saw right away that the patient had an arterial bleed and immediately sent him to the nearest ED.
Tracy says the experience showed him how valuable video visits can be for his three-physician direct care practice, 307Health. “My biggest hope is we can use telemedicine to improve the delivery of care,” he says.
Technology advances over the past decade have made telemedicine much easier to implement and integrate with other computer apps, according to health IT experts, physicians, and practice consultants.
However, establishing telemedicine within a primary care practice—especially a small one that can’t access the technical, financial, and managerial resources of larger institution—requires a calculated approach.
“It should be part of your strategic plan. You need to think about the workflow and the staff required,” says Robert Tennant, director of health IT policy for the Medical Group Management Association, headquartered in Englewood, Colo. “You have to have policies, the technology, the security, and the reimbursement all in place to make it work.”
Calculate the potential
Physicians need to consider not just patient demand but whether, and how, they’ll be compensated for telemedicine visits, Tennant says.
Some payers, including Medicare and various private insurers, do cover telemedicine. Because reimbursements for such services aren’t universal, though, physicians need to assess their payer mix and calculate whether offering telemedicine services makes financial sense, says Ashutosh Goel, MD, chief information officer, chief medical informatics officer, and senior vice president of IT for Bronson Healthcare, a health system based in Kalamazoo, Mich.
“They should look at their total patient volume, understand which of their patients are under some type of capitation model, which percentage of the panel is looking for these visits as a ‘retail’ service that they are willing to pay out of pocket for,” he says, adding that there’s no standard calculation for evaluating these factors to determine fiscal viability for telemedicine.
Goel says physicians might also consider researching whether any employers in their region are willing to pay for telemedicine visits for their employees and then partnering with those companies to provide them.
He also suggests using patient surveys and any related market data (generally compiled and sold by research firms) to help determine whether demand can support telemedicine in a practice.
Steven E. Waldren, MD, MS, director of the Alliance for eHealth Innovation, suggests that in addition to patient surveys, physicians log telephone calls of conditions that could be addressed with telemedicine.
Waldren advises physicians to calculate their monthly cost for providing telemedicine and then estimate how many visits per month would be required to see a return on investment.
Goel, a member of the physician committee at the Healthcare Information and Management Systems Society (HIMSS), a nonprofit organization promoting the use of health IT, says telemedicine makes the most financial sense for concierge-type practices or those with a large patient population covered under a capitation model (under which there aren’t reimbursements for individual visits, so there’s no difference financially whether the physician sees patients via telemedicine or in person).
John Sharp, MSSA, FHIMSS, senior manager of consumer health IT with Personal Connected Health Alliance, a nonprofit arm of HIMSS, says practices could also forgo seeking insurance payments for their telemedicine services and instead charge patients directly.
“That might still be worthwhile for
patients who see it as better than taking off a half day from work to come in,” Sharp adds.
Telemedicine has particular appeal for patients who can’t easily make it into an office: disabled patients; patients with chronic conditions who need frequent visits to stay on track; those with transportation challenges; and patients with compromised immune systems, experts say. So practices starting telemedicine need to establish guidelines on which patients and what conditions are good candidates for telemedicine services.
Tracy says he recently scheduled a video visit with a patient who was snowbound, for example, but he and others agree patients with certain conditions or symptoms need to be seen in person. Those include any exam where the doctor needs to physically touch the patient, as well as exams that require the use of specialized medical equipment such as stethoscopes.
On the other hand, patients with chronic conditions who need more frequent visits could invest in mobile apps, such as an otoscope app and attachment, as well as home devices, such as a connected blood pressure cuff or glucometer, and thereby make themselves good candidates for telemedicine
Sharp recommends physicians select a particular set of patients from that list and conditions compatible with telemedicine visits to use for a pilot program. (Patients with hypertension or diabetes who already come in for regular checkups to help stay on track make good candidates for a pilot program, for example.)
This allows the practice to evaluate its telemedicine plans and adjust its technology, policies, and procedures—such as how the physician’s camera is positioned to how patients submit data before the telemedicine visit—before rolling it out more broadly.
“Similar to in-person practice, when using telemedicine, a physician should ensure that patients retain their rights concerning privacy and secured health information, access to their medical records, and information about benefits, risks, and alternatives to proposed treatments or procedures,” says Latoya S. Thomas, director of the State Policy Resource Center at the American Telemedicine Association (ATA).