Telehealth in the trenches: Part 2

Last month I wrote an introductory article on telehealth and detailed the many reasons why pediatricians should consider providing telehealth services to patients. Several insurance companies are supporting direct-to-consumer (DTC) video telehealth services, which threaten to disrupt the “medical home,” and, given time, may reduce your patient volume and therefore your bottom line. In this follow-up article, I will describe the logistics of implementing your own office telehealth program. While straightforward, there are many considerations, including telehealth guidelines, payments concerns, and important technical details as well.

Recommended: A primer on telehealth

Guidelines for telehealth

As discussed in last month’s article, “telehealth” is a broad category. In general as practiced today, telehealth involves:

·      Store-and-forward services: ie, a patient e-mails a digital photo of a rash to you, or you send a photo of a puzzling rash to a dermatologist.

·      Home monitoring: A patient records blood sugars or blood pressures directly using a device that connects to a smartphone or tablet. Similarly, a patient’s weight, pulse oximetry, and vital signs can be recorded at intervals and this information sent to a home healthcare monitoring agency. These services help those who have been recently discharged from a hospital or who have a chronic illness.

·      Video medical visits between medical provider and patient: The patient may be in a hospital setting or at home.

Just last year, the American Telemedicine Association, the Federation of State Medical Boards (FSMB), and the American Medical Association all published guidelines for practicing telehealth.

I will present a general overview of the guidelines from these organizations as they relate to providing telehealth services from the perspective of an office-based pediatric practice.

Not unexpectedly, guidelines for telehealth closely follow common sense recommendations for delivering quality healthcare in general. Physicians should be licensed in the state where they practice and not provide telehealth services to patients who are in states where they are not licensed. Note that the FSMB is in the process of developing a multistate pact that would permit physicians licensed in certain states to provide telehealth services in other states.

NEXT: How to get paid for your services

Telehealth can be used for providing services to patients with a multitude of medical conditions including: asthma and allergies; rashes; attention-deficit hyperactivity disorder (ADHD) or behavioral health problems; diabetes; hypertension; upper respiratory infections; injuries; conjunctivitis; and back pain.

More: Just say no to Meaningful Use 2

Physicians must respect patient confidentiality per Health Insurance Portability and Accountability Act (HIPAA) guidelines. A physician providing telehealth from a medical office should ensure privacy of the video visit. Before embarking on video visits, patient should sign a permission/agreement form (see “Sample telehealth informed consent form"), indicating they understand how the video visits will be conducted, what security measures are in place, and what type of visits are appropriate for video. Additionally patients should be made aware of how much the visits will cost and how payment will be collected.

Video visits should be conducted using secure, encrypted technologies (more on this later). Documentation should be performed using traditional charting methods, recording patient demographics, visit chief complaint, relevant family and social history, history of present illness, review of systems, and results of the virtual physical exam. Consideration should be given that if a patient has a medical emergency, arrangements can be made to summon an ambulance or provide emergency advice if needed.

Some physicians recommend that video visits be limited to patients with whom there is an established physician-patient relationship. However, this recommendation is much debated because DTC services cannot meet this requirement, and these advocates for DTC services argue that when patients seek medical care at emergency departments (EDs) or retail-based clinics, this requirement is never met. This is usually the case of initial visits with specialists whether conducted face to face or via virtual visits. Additionally, there are other healthcare providers (behavior health specialists, health coaches, speech therapists, and others) who practice entirely via video visits, and the provider-patient relationship is established totally via video visits.

Payment: The return to fee-for-service

Keep in mind that until recently telemedicine visits have involved physician specialists providing care to patients in medical facilities; ie, hospitals and rural clinics. In researching this article, I discovered that insurance companies rarely pay for video visits when the patient is at home and not in a medical facility. You will need to check with the payers in your state. According to recent publications, 19 states and the District of Columbia have adopted laws mandating that private payers cover what the states deem as telemedicine services.

Medicaid payments for telehealth services also vary tremendously.^1,2

Note that DTC services charge a “reduced” fee compared with a typical office visit charge for a short telemedicine video encounter involving providing services in a patient’s residence via a smartphone, tablet, or computer. Typically, this fee is $50 or less. Some insurance companies are paying for DTC visits. In fact, many are encouraging patients to utilize DTC telehealth services, reasoning that many of these encounters will resolve a patient’s problems and reduce the number of unnecessary visits to EDs. A $50 fee is often close to an office copay, so many patients do not mind paying this amount because it provides services without missing work, traveling, and so on. The $50 fee is also less than the reimbursement for a level 3 visit ($70 or so).

Primary care physicians who wish to provide telehealth services to patients may need to provide visits at these discounted rates until such time that improved compensation may be negotiated with insurance companies when telehealth services become more of the “standard” of care. Keep in mind that pediatricians often provide treatments gratis, such as for head lice, conjunctivitis, and more, and usually refill or change prescriptions via telephone requests, also without charging the patient. Video visits may enable pediatric providers to recapture some of this previously lost revenue. Also a video evaluation of a sick child can prevent unnecessary visits to EDs, and at the other extreme, expedite treatment in situations where a parent may otherwise delay care for a potentially life-threatening condition.

If you have questions about the rules and regulations regarding telehealth services in your state, an excellent resource is the Center for Connected Health Policy’s State Telehealth Policies and Reimbursement Schedules (

).

NEXT: How can you connect to patients?

Getting connected

To conduct a video visit with a patient, you cannot merely communicate via Facebook or Skype. The HIPAA amendments to the Health Information Technology for Economic and Clinical Health (HITECH) Act specify that healthcare providers must contract with a business entity who assumes all responsibility for assuring that video communication between physician and patient is encrypted and secure.

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There are dozens of such services available at low monthly cost that will support your new endeavor. These services include TouchCare, eVisit, SnapMD, and others. Most charge a fee of between $100 to $300 per month and provide training and support. Providers are responsible for setting up a computer in their home or office equipped with a high-definition webcam (often present in most quality laptops), which costs about $100 to $150. Physicians also are responsible for purchasing a noise-cancelling microphone (USB or Bluetooth), which generally costs $50 to $100. At the patient end of the video encounter, just a smart tablet, smartphone, or webcam-equipped computer is required.

Software or smart-device applications are provided by the telehealth service. You simply send an e-mail link to a patient providing them with an access code and instructions, just as you would with web-conferencing applications.

You will be surprised how well smartphones or tablets perform in such encounters, and how your training and experience proves more than adequate to assess a patient via a video visit, perform a virtual exam (look at breathing effort, rashes, throat), arrive at a diagnosis, and provide some treatment options. In some cases (conjunctivitis, diaper rash, medication follow-up), you will find it easy to prescribe treatment and document your visit in your electronic health record (EHR) or in the online software provided by the telehealth service. In other situations, you may recommend that the patient visit a lab to submit a specimen (sore throats, dysuria), or recommend that a patient in distress be seen in your office or at an ED. It is also possible to have group sessions with parents to discuss common issues including new baby care, asthma management, or ADHD, for example. Creative providers also may provide slide shows or videos to embellish such presentations.

In researching this article, I’ve had lengthy discussions with 2 firms that provide telehealth services: CloudVisit and Secure Telehealth. I even had a demonstration using my iPad with the latter service. Each has a different approach to managing telehealth visits. CloudVisit (installed base of more than 100 practices) provides an online practice portal with scheduling, billing, and note-taking capabilities. Secure Telehealth (installed base of 600 practices) takes a more basic approach because most of its clients use an EHR for documentation and scheduling programs. It suggests that patients click on an icon placed on a practice’s existing website to initiate a scheduled telehealth visit.

As of this writing, I am investigating providing telehealth visits in my practice. The most significant obstacle is the payment situation because my clinic serves a large Medicaid population that is used to getting care without copays. To make these visits for this population possible, I would need to convince the managed Medicaid programs in my state to pay a reasonable fee for this service. Insured patients, however, are a different story. They would easily pay a standard or reduced office-visit fee because of the convenience of such a service.

In an era when you can order a pizza delivery with a mobile application, and not only talk into your phone but “to your phone,” I would not be surprised if our next generation of pediatricians will be providing a significant amount of patient encounters by video. It would be nice to be able to work from home at least part of the time.

REFERENCES

1. National Telehealth Policy Resource Center. State Telehealth Laws and Reimbursement Policies: A Comprehensive Scan of the 50 States and the District of Columbia. February 2015. Available at:

. Accessed June 5, 2015.

2. National Conference of State Legislatures. State coverage for telehealth services. Available at: http://www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx. Updated January 2014. Accessed June 5, 2015.

Dr Schuman, section editor for Peds v2.0, is adjunct assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.