The policies, technology, security, and reimbursement guidelines a practice needs in place to make telemedicine work
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.
This article appears in the 4/10/18 issue of Medical Economics.
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.”
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.
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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).
Physicians have a choice as to how they want to practice telemedicine: They can integrate it into their existing practice or they can partner with companies that offer such services.
Those who decide to integrate telemedicine into their existing practices to treat their own patients will have to select and then implement the technology, policies, and processes to make it work for them, Tennant says.
Although that’s the route many physicians take, practices can work with companies that provide all the infrastructure to enable video visits, Sharp says.
“The company either takes a larger portion of the reimbursement or requires a monthly fee or something like that. But the advantage is they provide everything out of the box for you. And they [tailor the site’s branding], so you put your own practice logo on it,” Sharp explains.
Health IT experts say these services allow physicians to treat both their own practice’s patients and possibly non-practice patients who seek services through the company’s own network.
Goel says he sees companies structure their payments based simply on per-patient visits. The prices under this model range from $50 to $100; companies may charge a technical fee on top of this. Goel says practices can establish a fee schedule to charge patients higher amounts, to ensure they make a profit, but he notes reimbursement models don’t support such pricing. As a result, such telemedicine services are used primarily in concierge practices.
Thomas says practices should:
Similar to advice usually offered for other new business arrangements, health IT experts say, physicians should ask if a company will allow the practice to pilot a program before signing a long-term contract.
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Practices need to know why they want to offer telemedicine services and articulate how and where they want this to work within their practice, Waldren says.
“Are you going to use it for off-hour calls? To offload some regular visits? To make it convenient for patients?” he asks.
Determining these objectives helps practices make smarter decisions when it comes to choosing the technology and building the policies and procedures for telemedicine, he says. For instance, a practice that wants to use telemedicine to connect patients with their own physicians might require just a secure video connection.
On the other hand, a practice using telemedicine to treat patients with chronic conditions might want a more robust system with functions such as dashboards for managing patient data that the entire care team can use.
Regulatory requirements for telemedicine vary from state to state, according to Waldren. For example, some states require physicians to have an existing relationship with patients they treat via video visits, while others don’t. Meanwhile, some states require parity between telemedicine and equivalent face-to-face visits to ensure the medical services physicians offer virtually mirror the quality they offer in person.
Similarly, physicians should review their malpractice policies to ensure their coverage extends to telemedicine services. Telemedicine service coverage can vary from payer to payer and from state to state.
The Center for Connected Health Policy offers resources to help physicians sort through rules and regulations as well as the state-by-state variances among them. (Find them at
bit.ly/CCHPCA-policies.) There are also state and regional telemedicine groups that offer guidance on such issues.
Similarly, practices need to work with payers to ensure they use the right codes for reimbursement, as billing codes for telemedicine can vary depending on the services and insurer and may be different than the codes used for the same services when performed during an in-office visit, Thomas says.
James F. Bush, MD, FACP, an internist serving as the Wyoming Medicaid medical director and chairman of the Wyoming Telehealth Consortium, says most EHR vendors offer telemedicine functions that bring together the video, audio and documentation components with little or no need for additional integration requirements. However, he and others say physicians could find that their EHR’s telemedicine functions might not offer all the features they want, in which case they’ll need to explore options from other vendors.
Health IT leaders say that while each practice needs to evaluate vendors based on the criteria specific to their practice needs, some common questions to ask when deciding on which one to choose would be:
They also advise selecting platforms that are HIPAA-compliant instead of using consumer services (such as Skype) or technologies offered to businesses that don’t have the same level of security requirements as healthcare. Waldren reminds practices to ask vendors for verification that they’re HIPAA-compliant.
Tennant advises physicians to seek out colleagues in similar-sized practices who have implemented telemedicine to ask about their experiences and the technologies they use. He suggests visiting the practice to observe telemedicine in action.
The good news is, most physicians won’t need significant hardware investments.
“For the vast majority of telemedicine, the commercial consumer-level products are more than adequate,” Waldren says, noting that the cameras in desktops and laptops offer sufficiently high resolution.
Physicians also should have headsets to ensure adequate sound quality and more privacy than the speaker functions embedded in laptops and desktops generally offer, health IT experts say.
Additionally, “you want to make sure your internet connection is fast enough to support video,” Sharp says, adding that physicians can test their connection using a free consumer platform (such as Skype) to see if their system works smoothly or if the video snags or crashes their computers (thus indicating the need for an upgrade).
Practices need to consider how telemedicine will fit into their services. That includes:
Determining whether the procedures for checking in and treating patients for telemedicine visits will mirror the workflow of in-office visits or whether the workflow needs to be tweaked; for example, practices might opt to have their non-physician staff gather needed information from patients at the start of the telemedicine visit as they do for in-office visits. Or practices could decide to have patients electronically enter information prior to their appointment.
Determining whether, and where, they can add automation and patient-entered information into the process.
Determining whether physicians will be the only ones to conduct telemedicine visits, and if not, under what circumstances other team members may conduct those visits.
Bush recommends training at least one point person for telehealth, with responsibilities for scheduling the appointments and sending out the appointment notices with the links or details on how to join the video visit. Related to that, physicians need to determine whether they’ll use telemedicine to handle urgent calls.
Experts also advise practices to consider how telemedicine will fit into the practice schedule. Sharp says some practices carve out blocks of time during their schedules for telehealth visits rather than having telemedicine services available at all times.
Practices need to consider their typical office rhythms and patient demands, such as whether they get a flood of appointment requests on Monday morning that could be handled more efficiently via telemedicine.
Sharp adds that practices piloting telehealth might consider planning only for a few hours weekly to test how well it works rather than starting with large blocks of time. They also need to determine, based on their patients’ needs and practice experience, how much time to allot for these visits.
A practice can work through all these questions before implementing telemedicine only to find that it isn’t well-received by patients. A practice might not see a return on its investment-at least not in the short run.
But physicians shouldn’t abandon telemedicine in such circumstances, experts say, but rather use the experience to evaluate how to better promote the service to patients and to refine their pricing.
Telemedicine can help practices be more efficient, and thus more profitable, as well as provide supplemental income to physicians. However, health IT experts don’t see it as a lucrative endeavor.
Still, practices offering telemedicine should seek to maximize the value of their investments, and that means letting patients know that it’s available, Waldren says.
“You’re going to have to market it to your patients and explain what they can and can’t do, so think about a marketing campaign,” he says.
The campaign should do more than simply say the service is available, Waldren adds. It should let patients know why it’s available, when it’s offered, and for what conditions.
At the same time, physicians should determine from the start what a successful telemedicine program should look like for their practice so they can establish metrics to judge their efforts as they get under way.
Physicians could establish objectives around improved financials, patient convenience, provider satisfaction rates, and/or patient outcomes. Whatever the anticipated benefits, Waldren says physicians should set how and when to measure progress in each area to determine if they’re succeeding with their telemedicine program.
He adds, “You want to check in frequently enough to make sure you’re making progress.”