Make telehealth work for your practice — even after you re-open

May 26, 2020

Peter Alperin, MD, an internist and vice president at Doximity, discusses how physicians can use telehealth to efficiently see patients, even after practices re-open.

Peter Alperin, MD, an internist and vice president at Doximity, discusses how physicians can use telehealth to efficiently see patients, even after practices re-open.

The following transcript has been edited for length and clarity.

Medical Economics: How do you define telehealth?

Alperin: Telehealth versus telemedicine is an interesting topic. Telehealth is a broad term that really, in my mind, refers to all the different things that you would do through a video platform that's both synchronous and asynchronous. So, if I'm having a conversation with a patient, or if I'm even having a conversation with another physician, it can also involve getting forms or other things that maybe are asynchronous. So those sorts of activities. And then when I think of telemedicine, I think really about the specifics of having that clinical visit with a patient. So that's kind of the way that I separate it in my mind.

Medical Economics: What are some misconceptions that that you think physicians have about telemedicine, telehealth, and the concept of remote care in general?

Alperin: It's a great question. And we've had a lot of those myths and misconceptions probably shattered over the past two months. I think the first misconception is that telehealth is something that you can't incorporate into your practice easily. I think it is been shown and I think we've proven that it's something not only that, physicians of all kinds, but primary care specialty employed, you know, private practice, can incorporate into their practice easily if they just put a little bit of thought into it and Like they say Necessity is the mother of invention. And that's really what I think has driven the, the conversation. Now, another misconception is that telehealth is somehow substandard care. And that it's, it's somehow you're not giving the patient as great a clinical experience. There's no question that there are a wide variety of things and a good number of things, and an in person visit is required for. But that said, If you as doctors have thought about how telehealth has worked for them, they're discovering that patients like it and actually for a good number of visits. For the physician themselves, it's proven quite effective.

Medical Economics: A lot of physicians are learning about telehealth on the fly. What have you learned and what have you heard from physicians about how telehealth has performed during this pandemic?

Alperin: What I've discovered in my own practice, and what from the dozens of physicians that I've spoken with, is that setting up that visit through telehealth really has done a couple things on the patient side, in particular. It's let the patient have more contact and more connection points with the physician. You know, one of the tricky things about having a patient come into your office is that it can be difficult to schedule, it can be hard to get on the calendar, so to speak. And what ends up happening is that that a lot gets compressed into that visit and a lot of questions get answered and every physician will talk about the as the patient's walking out the door, the one more thing that turns out to be another 30 minute conversation. So the appointments themselves can be very compressed and there's just a lot to do particularly in primary care. And on the physician side, you're now you're now able to have an additional touch point with a patient to maybe clarify some of the things that came up during that visit. So maybe clarifying some new medications that you talked about or the side effects related to medication, or some other particular clinical instructions that you had for the, for the particular visit. So those are some, I think, really important places where telehealth has improved care, it's also improved access, right? So access in general is something that is always an issue. And if a physician or a physician's practice is able to get, you know, have a wider number of patients that they're able to take care of, or a greater number that can only benefit both sides.

Medical Economics: What are some of the advantages of that and what are some of the limitations?

Alperin: The easier side is: what are the advantages of the in-person visit? The physical exam, there's no question that it is it is easier to do in person. That's how physicians have been taught for hundreds of years. And that is how the exam is designed. And there are certain things which there is no substitute and that drives those visits that need to come into the office. So there's definitely an advantage on in the office when it comes to that aspect of it. Also, being able to read a particular patient can sometimes be a little bit easier. You know, a lot of communication is nonverbal, and it can take a little bit of practice when you're having a conversation across the camera.

But the advantages of telehealth are not to be minimized. Like I mentioned before, patients may feel a little bit more comfortable and relaxed during a visit and they feel a little bit more comfortable knowing that they don't have to get every last thing and on This visit. And so some of those questions that you may have may be able to be answered in more depth and more completely and more comprehensively. The other thing is that you can, by talking to them more, you can actually see the longitudinal nature of some of the changes that you're making in terms of their care, say, a treatment plan with a medication or device. And you can catch them in their own natural environment, which can be advantageous in certain circumstances. So, like everything else, it's a tool. And that tool has to be used appropriately and you have to understand the advantages and the disadvantages of it.

Medical Economics: Right now, a lot of the regulations around HIPAA security have been relaxed. What tips do you have for physicians to manage and make sure that they're keeping privacy at the top of the list while also improving access?

Alperin: Implicit in your question are the waivers that have been granted by CMS related to the telehealth platforms that physicians can use during the COVID pandemic. And I think that was a great decision. Let's worry about some of the other things later; let's just create a system where physicians can get patients seen. But I will say that it's not going to be too long before those waivers are going to be either rescinded and regulations retightened are both.

It is, I think, very important for physicians to pay attention to making sure that the platforms are HIPAA compliant. So the technology that you'll utilize in your practice needs to have all the proper certifications because, let's face it, HIPAA is the law of the land and it is a requirement and it's there for the patient's best interest. I would say make sure you have a reputable partner and vendor partner when it comes to your technology solutions.

Medical Economics: We're moving into a phase where lots of the economy is re-opening. And physicians are going to start seeing patients again in their practices. How do you create a workflow that balances seeing patients going room to room while also keeping up the good habits of telehealth that you've been developing?

Alperin: The first thing is you need to set up specific times during your day that you'll have in- practice visits as well as telehealth. But that doesn't always necessarily work, right, because there may be a particular telehealth visit that you need at 10:30 in the morning on a Wednesday, which is the time that you've set aside for in-office visits. So having some sort of triage system is critical. Having that system be in place so that your staff can help understand what are the criteria that you want for telehealth versus an in-person visit. And then building, as best you can - and this is tricky - some flex in your schedule so that you have those opportunities to do those telehealth visits in the middle of otherwise, blocked off time.

The other thing that's important is: Telehealth is here to stay and making sure that you go with a platform that's super easy to use and just works, will help you not have to fumble around and have that block of time be wasted. That's a lost opportunity both for patient care, most importantly, and let's face it, revenue as well.

Medical Economics: In terms of patients with chronic conditions - patients with diabetes patients with heart conditions, asthma, COPD, all the really tough chronic conditions that primary care physicians are treating on a daily basis - what role does telehealth have for managing those conditions? What's the best use of telehealth with those types of patients?

Alperin: That's a great question. And I think it's a really important point. Really the key element that distinguishes those conditions versus, say, a cut on your finger, is that there are longitudinal conditions that require long term management, and there's no better solution for long term management than multiple touchpoints with the patient. And so telehealth and telemedicine allows you to have those multiple contacts with the patient in a much more efficient way that's convenient for both of you and for the patient. So let's take, for instance, a patient with diabetes. There's a fair number of medication changes that you need to do. You can do some of that by secure messaging, but being able to have a five minute conversation or a 10 minute conversation with a patient and being able to answer those questions face-to-face can be huge. And it can help you can learn all sorts of things about the patient; perhaps they’re taking their medications wrong. They're taking one medication at the wrong time of the day or before a meal or after meal really depending upon the particular clinical scenario. And so, that ability to contact the patient more frequently, it sort of harkens back in a lot of ways to the era of the home visit. Obviously, that's not the most efficient way to take care of patients, but there's a tremendous value to seeing a patient in their own home environment and the telehealth approach allows you to have that good relationship with the patient and talk to them more often. You might learn some things that they may have otherwise forgotten because your next in-person visit wasn't scheduled for two months from now.

Medical Economics: What advice do you have for physicians to feel more comfortable on video?

Alperin: It definitely takes a little practice. And I think that's the key, you know, just as physicians in medical school, learn how to practice the neurologic exam or the cardiovascular exam, learning to communicate with the patient on video is important. So what I would say is, figure out where in your office you're going to do it, are you going to do it from your personal office so you can have a different room. Often times you'll use your phone. If you are using your phone, which is oftentimes very convenient, and the most appropriate way, maybe always sit in the same place, think about the lighting that you have. Think about how you look on camera. And so what all of that really comes down to is do a little bit of homework, set yourself up, see what you look like on video. You also need to think about the audio as well. Really think about how you're going to be able to hear a patient clearly. And so have something dedicated to that. It's again, it really comes down to just spending a little bit of prep time and it really doesn't take very much you can be set up in you know in 20 minutes if you're if you're really good at it and otherwise an hour which really isn't that much when you think about it.

Medical Economics: And the other end is the patient and most people are pretty versed in basic technology such as smartphones. But obviously you're going to have patients that might struggle with technology. What what's the role of a physician in their practice and their staff in helping patients access telehealth?

Alperin: I think this is a really key point that is under appreciated. A lot of the telecommunication platforms and telehealth platforms that are out there are not necessarily the easiest thing to use. And I think ease of use is critical. Something that's easy, safe and reliable is really what you're after, because a lot of the patients that you're going to be taking care of may be elderly, and you want something that works across all platforms. So whether that person has a smartphone or not, whether that person has a Mac, or they have a PC-based system, it needs to work across everything. And ideally you want a system that doesn't require the patient to have to download something. This may be the first time that they've done that. And they may not understand that their computer won't let them download something because their permissions are set up, or they haven't rebooted their computer for three years. And you know, it's got a lot of, you know, updates that haven't been done. And so things aren't compatible.

We've designed a system at Doximity, and it just works. You need to send a text to somebody and you want that visit time to be to be as fruitful as possible. Because otherwise that patient will be frustrated, you'll be frustrated, you'll have to reschedule you won't be able to bill that visit. And so again, easy, safe and reliable.

Medical Economics: How would you go about evaluating telehealth program?

Alperin: That's a good question. I think it's like anything else. I think if you are comfortable enough, and frankly, humble enough to admit to your patients, hey, this is as new to me as it is to you. How did I do? What did you like? What did you not like?

That's probably something that could be a little bit easier done in person, particularly with patients, maybe you've known for a long time. But I really think just soliciting direct feedback, maybe at a subsequent telehealth visit, or if you have the opportunity at the end of the visit, ask the patient: So how did this go for you? Were there things that you thought we could have done better? Were there things that you liked about it? How did I sound? How is the volume? Did you find the system that I've employed easy to use? I think what you'll find is patients are quite flattered when you ask them how that you can improve.