With an estimated 90% of Americans under some form of stay-at-home order, patients are much more limited in how to seek out the health care they need. One consequence is the phenomenal growth of telemedicine, which is defined as “a two-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site”.
If you’re a healthcare provider who doesn’t offer a telemedicine service, you may want to consider this as an alternative for your patients. This not only gives them continuity of care during times when office visits are difficult but this can also be part of your regular service offering to expand your patient base.
Before you start, please make sure your malpractice insurance policy covers telemedicine. Note that some medical specialties (like Psychiatry and Sleep Medicine) may have more meaningful online patient interactions than others.
Having said that, there are several things to consider as you set up your telemedicine practice. We call them the 5 P’s of Telemedicine: Platform, Process, Person, Packet and Payment. Let us discuss each individually.
To start with, you’ll need a telemedicine platform. Any platform is fundamentally a two-way live audio and video system. We do want it to be easy to use, fast to implement, HIPAA-compliant, compatible with most devices, and inexpensive.
So what’s the best platform?
There are three sets of options:
- Use a platform that already comes built-in with your Electronic Medical Records (EMR). This typically is the fastest to implement and integrates perfectly with your process but this also means you have no choice in terms of pricing or customer service. This often requires your patient to have an account with its patient portal. These EMR’s include eClinicalworks, Centricity and Epic.
- Sign up for a third-party platform that is compatible with your EMR. Depending on your EMR, there may be a few or none. You can ask your EMR vendor if they recommend any compatible platforms. This includes platforms like my ePhysicians, NewPatient and MyCarePlan.
- Register with an independent third-party platform. This gives a lot more choices and can be less expensive. Since it isn’t integrated though, you’ll end up needing to synch calendars and other information. Some platforms are Zoom, SecureVideo, Doxy.me, Webex, Vsee and Vidyo
If you don’t have a lot of IT support and your EMR has its own telemedicine portal, the first option may be the most practical. If you have a great support infrastructure, the third options will give you a lot of flexibility in terms of features and pricing. The second option can be considered a balance between simplicity and options, assuming your EMR has third party integrations.
Some features you want to check are compatibility with windows, apple or android systems, HIPAA compliance like end-to-end encryption and Business Associate Agreements, notifications through email and text, waiting room queues, online documents and file transfers, recordings and screen capture.
Pricing formulas vary; Most are based on the number of providers, users or visits. They tend to be multi-tier so it will be a good idea to have an fair estimate of the size of your telemedicine practice to get the best deal.
To learn more, you can do a web search and contact their sales teams. Most information you’ll need are in their websites. You may also check online resources as well as your professional associations.
The second consideration is the process. While this is fundamentally the same as in-facility visits, not having the patient physically on-site does require some adjustments.
For example, filing up physical forms and vitals will be different. Before the visit, patients will need to fill up online forms, do technical checks and will need some orientation on the use of the platform. Eligibility and pre-authorization, if needed, can still be done offline, as usual. Co-pays or cash pays can be done online.
Note that patients should consent to telemedicine and to seeing you if you are not specifically licensed for that state where the patient is located.
Regarding payment, some platforms require payment before the appointment or can be done right after. Patients can be contacted immediately after a televisit for any follow-ups. Other post-visit activities like referrals and prescriptions may still be done online.
It is a good idea to map your current process and see how each step needs to be changed in a telehealth setting.
You’ll need a facilitator. Your time as a provider is too limited to wait on a patient or teach a patient how to shift from a rear-facing to a front-facing camera. And if you need a little more time with a patient, someone has to keep the next patient on queue aware that they’ve not been forgotten.
A good facilitator, like a virtual assistant, makes sure all preparatory steps are done. The assistant coordinates the current visit and does post-visit work like collecting payments and sending out orders. You need a good communicator with enough clinical acumen, great with documentation, a dash of tech support and a lot of patience and empathy.
I remember being asked a long time ago to spell “Mississippi” with one “I” (after covering one “eye”). Seeing a patient in a 2-dimensional computer screen is like assessing them with one eye covered. The lack of depth perception however shouldn’t keep us from making sure we dot all the i’s and cross all the t’s.
Most notably for new patients, we’ll need some way to get documents (that would typically be in the patient packet) filled up and/or signed. Some services allow forms to be filled up online as well as accept eSignatures if necessary. Some of these are integrated with the EMR’s or the telemedicine platform.
Some documents, like drivers’ licenses, can be displayed on the screen during the tele-visit. Most platforms will allow you to take snapshots. Additional documents, like telemedicine consent forms, will most likely be required as well.
Soon after adopting a telemedicine platform and seeing a lot of happy patients, the doctor asked the medical assistant, “how are we getting paid?”.
First, there’s no physical front desk counter where a patient can swipe their credit cards for their co-pays (or full cash pay).
Second, there are nuances for billing for telemedicine consultations that should be considered. Sans a federal or state waiver, telemedicine may inadvertently invite out-of-state patients.
For patient payments, check if your current merchant services can allow you (or your assistant) to manually enter charges to a secure portal or if they can have a “widget” that you can put on your website for patients to fill up. Many EMR’s and Telemedicine platforms can provide these as well.
As a principle, you need to be licensed in the state where your patient is located. You may apply for licenses across multiple states and some recent regulations allow doctors to practice across state lines. There have been many waivers to this requirement due to the current pandemic so do check your local boards and professional associations for more guidance.
For insurance payments, do familiarize yourself with the appropriate procedure codes and modifiers (if applicable) for telehealth. Note that some telehealth services will not count as consultation, like communicating test results, scheduling appointments, and other interactions that do not involve evaluation and management or care management. Ask your biller for the appropriate codes and documentation support requirements.
I worked with a psychiatrist who set up a completely virtual practice where the entire chain of care and revenue cycle is cloud-based. She had among the lowest per visit business costs that I’ve seen but was one of the most responsive in terms of communications and services.
You do not need to go completely virtual or see all your patients via telemedicine to enjoy benefits like simpler operations and reduced costs. You can start by seeing a few patients via telehealth and go through the entire process.
This is a good project to start now; just consider the five P’s to help make sure you have all your bases covered. Good luck!