8- TELEMEDECINE & TELEHEALTH by PHARMAGEEK

Many healthcare providers have been working to define and implement a telehealth strategy over the past several years. In the initiatives I’ve been involved with, this has generally been a slow march through figuring out the legal, reimbursement, compliance, and physician staffing and compensation implications.

With current events, this timeline has obviously accelerated, with IT and clinical staff being tasked with standing up telehealth programs in weeks, if not days, to deal with COVID-19.

Telehealth is a key tool to limit visitors at a time of overcapacity, to reduce the risk of infection spread, and to manage non-Covid-19 care when clinics are closed.

Below I outline some of the key considerations I have seen in my work with telemedicine, and what that might mean in the near term for health systems scrambling to deploy telehealth functionality as soon as possible.

Here focused on synchronous, clinician to home-based patient communication, although launching other forms of telemedicine (clinician to clinician, virtual ICU, etc.) will have similar concerns.

TECHNOLOGY

For both hardware and software, there is limited time to go through assessments and procurement processes.

Given the time-sensitivity, the focus should be on understanding what is available to be deployed immediately. For hardware, that may mean distributing laptops to ensure clinicians have access to camera and microphone-equipped PCs, or even redistributing hardware from training rooms.

For software, this will entail understanding precisely what applications you currently have available, and what the licensing implications would be to scale up to additional users.

If a new application or additional licenses are necessary, it is important to pull in legal and supply chain as soon as possible to ensure an efficient contracting process.

OPERATING MODEL

The technology for telehealth is relatively easy, but getting clinician, compliance, and revenue cycle leadership buy-in is not. I recommend immediately standing up a taskforce with accountability for decision making and defining policies and procedures.

This group should include your IT, EMR, HIM/privacy, compliance, and physician leadership. They will be tasked with determining who is staffing the telehealth service, what the patient consent process is, patient and clinician support, and how documentation will be entered into your EMR.

Since time is of the essence here, pulling this group together for a couple of long work sessions is likely the most expedient route.

TRAINING AND SUPPORT

You will need to be able to quickly and efficiently train your providers, IT help desk, and scheduling and registration staff. Reception and call center staff will need to know the basics to direct patients to online appointments.

Clinicians will need tip sheets on configuring hardware, installing software, and managing appointments and documentation. Help desk staff will need to understand setup and troubleshooting, including working with “non-standard” devices as clinicians work from home.

You will need basic how-tos for your patients, and coordination with your marketing and web teams to publish information and links to your telehealth service.

LONG-TERM PLANNING

The version of telehealth that you roll out overnight is not likely to be the ideal model.

Once your immediate telehealth service is operational at scale, your focus can turn to the longer-term view. This plan should be focused on patient and provider usability, integration with your existing patient portal and digital front door, and seamless interoperability with your EMR.

Scoping out the new interfaces, services, or UI integration will allow you to plan for and allocate your team over the coming weeks. While the immediate need for Covid-19 screening is urgent, telehealth will continue to be very relevant over the coming months to allow non-Covid-19 business as usual for those with chronic conditions or requiring prescription refills.

Telemedicine is one of the most notable advancements making waves in the digital transformation of healthcare. Telemedicine poses wins for healthcare organizations seeking to improve patient access while controlling costs, as well as healthcare consumers looking for more convenient ways to engage with providers.

With 71 percent of providers reporting the use of telehealthand telemedicine tools, it’s clear that the industry is sold on the benefits of virtualized care. Telemedicine market projectionssuggest that the industry will reach roughly $20 billion by 2025.

The patient and provider benefits of telemedicine are manifold—including reduced readmissions through remote patient monitoring, reduced costs via virtual access to specialists, and improved patient engagement—but barriers to adoption still linger. Here are five key challenges giving healthcare executives pause when it comes to telemedicine adoption and recommendations on how to successfully navigate those hurdles.

1) Understanding what comprises telemedicine. Due to varying state and federal definitions, as well as variance between Medicare, Medicaid, and commercial payer guidelines on what constitutes telemedicine, confusion still exists regarding what services will and won’t be reimbursed. Establishing a keen understanding of what virtual services qualify and how those services are reimbursed for each payer is vital. This will lay the foundation for quantifying the potential revenue impact of adoption.

2) Concerns around the cost to implement. Costs associated with telemedicine program adoption can include a myriad of factors, from video conferencing adoption to remote patient monitoring expansion. To mitigate the potential for expense sprawl, executives should identify key, phase-one telemedicine service offerings. Weigh earnings potential against anticipated program implementation and support costs to justify those telemedicine coverage areas.

3) Added data vulnerability. With healthcare security breaches on the rise, executive teams remain cautious of any patient data exposure risk. Many view virtual care delivery as an additional layer of potential threat. As with other IT implementations, thorough security protocols and routine audits should be put in place to guard against the real-time exposure of protected health information (PHI).

4) Potential for fraud and abuse. Telemedicine agreements can be subject to federal kickback laws, particularly in situations involving referrals for additional services. Providers must remain up-to-date on the regulations governing telemedicine services to ensure regulatory compliance and proper eligibility for reimbursement.

5) Patient awareness of and trust in virtual care offerings. Even with the proper broadband and internet resources in place to support patient adoption of telemedicine, providers may encounter patient reluctance to engage virtually. Healthcare organizations must cultivate trust by educating patients on offerings and what they can anticipate during virtual visits. Providers should also address security concerns with patients.

To ensure that engagement in telemedicine is a long-term trend as opposed to a short-term fad, healthcare providers will have to address and overcome these challenges. By implementing a telemedicine strategy that addresses these challenges head-on, providers can overcome barriers and rise to meet growing consumer demand for more convenient provider engagement options. As more healthcare organizations pivot to embrace new digital health platforms, telemedicine adoption, specifically, is quickly emerging as a key differentiator in an increasingly competitive landscape.

For medical students with the University of Arizona College of Medicine – Tucson, weeks of suspense will end on March 15. Otherwise known as Match Day, it’s the day the students will learn where they will go for their residency training, in their chosen medical field, after they graduate from medical school in May.

Sarah Joy Ring, who has completed the College of Medicine – Tucson’s Rural Health Professions Program and a 16-week Rural Health Distinction Track, is hoping for a residency focused on both pediatrics and emergency medicine, potentially in a rural location.  Her “capstone” paper, an in-depth research project that all Distinction Track students are expected to complete, carries the impressive title of “A Survey of Rural Emergency Medicine and the Discrepancy of Care for Pediatric Patients that Present to Rural Emergency Departments.”

During her training, she had opportunities to see how important telemedicine can be in rural communities.

“I was at sites that had telemedicine capabilities and spent some time chatting with the physicians about them. "I can specifically remember two experiences, one while on my family medicine rotation in Tuba City (in northern Arizona, where students learn about American Indian healthcare) and one during my RHPP summer in Flagstaff” (also in northern Arizona).

“Tuba City experiences a significant shortage of mental health providers in general, and specifically for children and adolescents," Sarah says.

“As such, they found using telemedicine helpful to connect the children of that region with services that they would otherwise struggle to receive, due to having to travel large distances to receive help, which incurs financial and time burdens for families.

“Moreover, a point that I found particularly enlightening when learning about this service, was with regard to what it means to live in a small population where it is quite likely you know most people living in the region," Sarah says.

“The physicians found that because of this, many adolescents experiencing difficulties often felt uncomfortable sharing with people who lived in the region, out of fear that they may tell someone, or that they were themselves a relative or family friend, which can be a common experience. Having someone to share with who lived out of the region and was not specifically invested in the region and an integral member of the community made many of these adolescents more comfortable with disclosing their experiences.  

“I also worked on writing about how telemedicine can be used to augment pediatric services in rural emergency departments for part of my "capstone" project and found some very positive results from multiple studies. For critically ill patients, one study found that in particular, telemedicine consults improved the access to critical care specialists, resulting in a reduced frequency of physician-related medication errors. Moreover, another study found that parent satisfaction was higher with telemedicine consults than with phone consults, which is a particularly important outcome when caring for pediatric patients and their family. Many of these same findings also translated to the pre-hospital environment, where ambulances that utilized telemedicine resulted in better assessments, more interventions in the pre-hospital environment, and improved outcomes for pediatric patients in pre-hospital care. 

“Overall," Sarah says, I think that we will continue to find that telemedicine is an excellent resource for rural providers that allows patients to have clinically significant access to additional resources and care that would otherwise be difficult or unavailable to the region."

Using telehealth technology still requires good bedside manners - just call it your screen side or website manners. So what do providers need to know that is different between an in-person encounter compared to a telehealth encounter? 

The space involved with making that first impression via telehealth is significantly smaller than meeting in-person in a clinical setting.  Besides being two-dimensional, your space is limited to the size and quality of the monitor projecting your image on the other end of the connection. 

You only get one chance to make a first impression – so make it good.

Important factors to consider to help develop and maintain a positive patient-provider relationship:

Prior to encounter – being prepared is always the best practice.

• Equipment – understand how to use and test; know who to contact to troubleshoot; ensure good placement of the camera, microphone, and speakers
• Physical space – clear of distractions; good lighting; private and secure (HIPAA)
• Provider Appearance – professional; solid, non-distracting (preferably light blue) colors
• Preparation – review patient history chart/file

During the encounter – a little extra explanation can go a long way to foster relationships.

• Confirm connection quality (hear/see) and security of space (HIPAA)
• Introduce self (and others), organization/location
• Have patient introduce self and any others in the room
• Explain the process of taking notes, and only briefly looking away from the camera as necessary, otherwise maintain eye contact
• Periodically ask the patient if he/she has any questions or anything to say
• Reiterate any instructions or follow-up procedures for a patient prior to disconnecting

Developing your screen-side manners in today’s telehealth world is just as essential as developing good bedside manners. 

Patients still need to feel they are being heard and understood by their provider whether in-person or via video connection. The tasks that happen during an in-person visit, (e.g., jotting down notes, or looking at an image), are seen directly by the patient.

These same actions may not be as visible via video, and require some explanation to keep the patient engaged. The patient still needs your full attention.

Empathy is no less important in telemedicine. Being prepared, clearly communicating, and focusing on your patient will help foster a positive patient-provider relationship.

 You can still make meaningful eye contact via telehealth, but the trick is looking directly at the actual camera, and not the projected image of the patient on your screen.

Body language can speak louder than words, but telehealth creates a situation where not all body language is actually visible. 

While a thoughtful hand to the chin while thinking maybe commonplace, on video the same action might communicate disinterest. 

Controlling reactionary movements is vital for telehealth. While standing bedside, a simple action like shifting weight from one leg to another has minimal visual impact compared to being on video and then seeming to shift out of the view of the camera.

Similar to developing a good bedside manner, a good screen-side manner takes practice.  Telehealth is unique in that you can record yourself and review the video before ever connecting with a patient.

By examining your recording, you can get a better understanding of the patient’s perspective of the telehealth connection. This process allows you to make adjustments that might not happen otherwise, creating the best patient encounter possible.

Practice EHR discusses net benefits of telemedicine for Urgent Care Centers.

Telemedicine is becoming the new norm for giving and receiving care. Today’s patients are more connected than ever before and 64 percent of Americans report they would seek care via telemedicine, according to an American Well telehealth survey.

In its early stages, telemedicine seemed like another on-demand solution taking patients away from urgent care centers (UCCs). Today, urgent cares are realizing the benefits of integrating telemedicine into their operations, such as better flexibility, accessibility and in some cases, better patient satisfaction and outcomes.

Fortunately, telemedicine also has financial advantages. Telemedicine empowers UCCs to provide a convenient and cost-effective service for patients, while at the same time improving revenue. Have you considered telemedicine for your urgent care? Read on to learn more about the financial benefits of telemedicine:

Net-Benefits of Telemedicine

1. Increase the number of patients you see each day.

Telemedicine helps you work more efficiently and see more patients in less time. A virtual visit takes less time than an in-person visit, allowing your urgent care to increase the number of patients seen in a day, without having to extend office hours. For example, a clinic with three providers that completes two virtual visits per day, at an average reimbursement of $50, will earn $109,500 in additional revenue in just one year.

For UCCs who do feel the need to provide extended office hours, telemedicine is a feasible and cost-effective solution when you have a cloud-based electronic health record (EHR) with integrated telemedicine capabilities. Consider virtual extended hours, where a patient can be seen via a virtual visit conducted by a remote on-call physician. This idea eliminates in-person visits during extended hours, which keeps costs low, drives revenue for your clinic and at the same time provides better accessibility for patients who may be in need during those off-hours

.

2. Better allocate your resources.

Today, consumers have more options than ever before when it comes to their care. Long wait times can result in low patient satisfaction and fewer patients. If your clinic is experiencing long wait times, consider how you can incorporate telemedicine for services that don’t require an in-person visit, like for the flu or an emergency medication refill. Providing virtual visits for these scenarios is a much more efficient and cost-effective way for your patients and your clinic.

Telemedicine can also help multi-location UCCs balance their patient volumes and wait times, without having to spend money on additional resources. The Journal of Urgent Care Medicine cited an example of an urgent care that decreased patient wait times and increased patient satisfaction by equipping facilities with telemedicine capabilities in two locations. In other words, UCCs can leverage providers in lower-traffic locations to conduct virtual visits immediately and remotely for patients who are waiting to be seen at the busier location.

3. Reach more patients.

In addition to load balancing, telemedicine can easily enable UCCs to reach a larger pool of patients to generate more revenue. Urgent cares who use telemedicine can expand their services to reach patients across one state or multiple, instead of being limited to patients who only live within a 3-5 mile radius.

4. Achieve competitive advantage.

Research from Accenture indicates patients want a better healthcare experience and they are leveraging technology, such as telemedicine, to do so. However, the same research also suggests patient demands for virtual care options are outpacing what’s currently available. This provides a significant opportunity for urgent cares. UCCs were the catalysts for convenient, on-demand healthcare; those who continue to evolve with their patients will successfully differentiate themselves in today’s competitive healthcare market.

To continue to lead in the on-demand market, urgent care centers will need to adopt technology, like telemedicine to meet patient expectations. The good news is telemedicine is a smart investment that can result in improved efficiency, patient care, cost-savings, revenue and more. Incorporating telemedicine into your UCC isn’t difficult, and there are affordable, telemedicine solutions on the market today. UCCs that incorporate telemedicine, have a lot to gain and very little to lose.

Telehealth has emerged as a critical tool in providing health care services. [1] The practice covers a broad range of medical technology and services that collectively define the discipline. Telehealth is especially beneficial for patients who live in rural communities and other remote areas where medical professionals use the Internet to gather and share information as well as monitor the health conditions of patients by using peripheral equipment and software such as video conferencing devices, store-and-forward imaging, and streaming media. The following information details important factors that are shaping this burgeoning field.

The Changing Face of Telehealth Law
Today’s competitive health care marketplace has created an environment where patients demand lower costs, higher service quality, and convenient access to services. [2] Telehealth is an innovative and valuable mechanism that provides patients with efficient access to quality services. Lowering costs and removing barriers to service access, are critical components in promoting patient wellness and population health. Convenience and cost-effectiveness are important commodities in the modern health care marketplace, as patients tend to avoid treatment that is difficult to access or too expensive. As a result, telehealth technology is emerging as a preferred choice among patients and providers. Telehealth has also attracted the attention of US legislators. They utilize this tool for improving the competitiveness of American health care services. This is especially important, seeing as health care represents 17 percent of the nation’s gross domestic product (GDP). In fact, the resource has helped to define the role that lawmakers play in ensuring that patients benefit in a competitive health care market.

Reimbursement for Services Delivered by Telehealth
The laws regarding reimbursements change regularly as more service providers incorporate telehealth technology into their practices. Reimbursement procedures can vary by state, practice, insurer, and service. [3] Care providers need to understand several facts, regulations, and laws to navigate Medicare telehealth reimbursements. They must first scrutinize whether the distance between the facility (the originating site) and the patient is far enough to qualify as a distant site. The location must also qualify as a Health Professional Shortage Area (HPSA) per Medicare guidelines. Additionally, the originating site must fall under Medicare’s classification as a legally authorized private practice, hospital, or critical access hospital (CAH). For instance, the Centers for Medicare and Medicaid Services ranks the Harvard Street Neighborhood Health Center as a top facility in need of physician services based on these criteria. Care providers must also use proper insurance coding to be reimbursed for hosting services that use telehealth technologies. For now, collecting reimbursements for telehealth services remains simpler for practitioners who limit the scope to which they apply the technology.

Telehealth or Telemedicine?
The term ‘telehealth’ is gaining popularity among medical professionals, compared to the original term, ‘telemedicine.’ [4] Some medical professionals use the names interchangeably. However, telemedicine is a term that may apply to the application of any technology in the clinical setting, while telehealth more distinctly describes the delivery of services to patients. Telemedicine is a familiar term, but telehealth more appropriately describes the latest trends in using technology to deliver treatments to patients. Depending on the organization, service providers may use a different definitions of telehealth. Although the basic premise remains similar, the context may change according to factors such as organizational objectives, and the needs of the patient population being served. Medical experts do agree on one point; telehealth is an innovative way of engaging patients, and it is highly beneficial for both providers and patients.

The Road Ahead
There are several areas where telehealth medicine could make a significant impact. It could be used as a tool to remotely monitor patients who have recently been discharged. It may also help treat individuals with behavioral health issues who might normally avoid treatment due to its high cost, or to avoid any perceived public stigma. [5] The largest area where technology could advance medicine is in treating the chronically ill. These patients usually require many visits with several specialists who may practice at different and distant originating sites. To move telehealth forward, organizational leaders must present evidence to peers and patients that the technology offers value. In addition, care providers must work to transition patients from using telehealth services only for minor conditions (for headaches, colds, etc.), to accepting the technology as a viable replacement for costly physician office visits. Advocates for telehealth medicine must also develop quality controls, so that this potentially transformational tool can maximize its problem solving capabilities and its service effectiveness. To harness the benefits of telehealth technology, America’s brightest medical professionals (both experienced and up-and-coming) must make a concerted effort to incorporate the tool into their practices and make it a regular service offering. Today’s medical students — as they enter a world where telehealth is becoming more pervasive — can take part in what might be a monumental change in the way health professionals think about medical treatment.