Practicing telemedicine

Doctors who haven’t yet embraced telehealth are increasingly pushed to do so—whether it’s just telecare-based emails and patient portal messages to something more involved, like telemedicine-based virtual visits. And why not? Practicing telemedicine has become a crucial part of modern healthcare. Many patients now prefer telehealth, particularly for routine care, mental health care, minor illness and chronic disease management. The perceived convenience and cost savings, however, often blindside the hidden truths of how complex and challenging telehealth can be. So much so that many doctors discuss on Reddit and TikTok how they are breaking away from telehealth, or at the very least, limiting the amount of telemedicine they provide. Telehealth has been around since 1997, but the notion of physicians conducting regular online visits with patients grew to its current point where it’s almost expected, thanks to COVID legislation that expanded coverage for telemedicine, the CDC and WHO stressing the need for social distancing and a Federal initiative that helped cover the cost of the internet. In April 2020 telemedicine usage in the United States was at its peak, accounting for 69 percent of doctor-patient visits. That number has since plunged but even so, patients who still visit brick-and-mortar practices are increasingly demanding the option to mix it up with the occasional virtual visit. In fact, 60% of patients say they are interested in using telemedicine services. Hesitation is warranted. Even though patients report being more satisfied with their interactions with physicians when using telemedicine, and they feel more connected to their healthcare providers, feedback from doctors is hit-and-miss. Many describe how telemedicine can be tough and not always efficient. For instance, phone calls and video conferencing aren’t always enough for physicians to make some diagnoses. Also, it can be expensive to set up, involve a lot of effort to stay abreast of changing guidelines and keep data secure and HIPAA-compliant. Then there’s the patients themselves. Over 70 percent of physicians reported that the most common barrier to using telemedicine is because patients had difficulty using the tools. Some dealbreakers for physicians were rooted in patient behaviors. Some patients don’t treat telehealth visits with the same level of respect and attention as in-office visits. For instance, patients might connect while they’re still in bed, or when they’re connected, they don’t even look into the camera. One physician reported that a patient logged in naked while in the middle of spooning in bed. Some patients connect while the tv is on loud in the background, or when they’re in the middle of chaotic environments, like people arguing in the next room. Another big issue is with internet and device reliability. Even though telehealth became more mainstream during the pandemic, challenges persist. It remains inaccessible in areas without internet or proper speeds. And there is still uncertainty about how using telemedicine affects patient outcomes over time. Here are some factors to consider before diving into telemedicine.

Decide your scope of support

Your decision here will affect your practice’s bank account, staff and work-life balance. 1. Think about the extent you want to invest in telehealth. Do you want to go all in with telemedicine video conferencing, with online scheduling, assessment forms, a virtual waiting room, a downloadable app and dedicated IT support? How about only audio instead or as an option? Are you interested in telecare, where you take responsibility to monitor a patient’s wearable devices, such as blood pressure cuffs and glucose readers? Whatever you decide requires its own HIPAA-compliant software, training and learning curve for you and your patients. 2. Decide on whether you want to conduct telehealth from home, from your practice or both. Health care providers should always use private locations for telehealth and implement reasonable HIPAA safeguards for protected health information. If you work from home and have two roommates, you have to carve out a dedicated space. 3. Decide on the hours you’ll dedicate to each service. Mornings only? Tuesday evenings until 7:00 PM? Every other Saturday from 9:00 AM to 11:00 AM?

Keep abreast of guidelines for practice and payment

1. HIPAA compliance is just the beginning. There are also strict guidelines for prescribing controlled substances, federal regulations for Medicare and Veterans Affairs, state laws for Medicaid, licenses for every state where you practice or have telehealth patients, and of course, private insurance reimbursement. Moreover, the guidelines keep changing. A few years ago, when telemedicine was finding its footing, doctors and patients were allowed to video conference using widely available apps like FaceTime and Skype. Not anymore. Regulations now dictate that video conferencing has to be completely secure and ensure patient privacy. Other regulations loosened. For instance, the Centers for Medicare & Medicaid Services used to require telehealth services have both audio and video, whereas now, visits can be conducted over the telephone (with audio only). Most telemedicine rules adopted during the COVID-19 pandemic will remain in effect through the end of 2024. 2. Map out a balance sheet of projected income from copays, reimbursements and additional charges. Reimbursement for telemedicine from private insurers and Medicaid were not always the same as for in-person visits. That disparity was a critical disincentive. To encourage doctors to start or keep up with telehealth, Medicaid increased reimbursement amounts so that providers were not paid less. And it worked. Nearly a quarter of U.S. adults over 65 have had a video visit during the pandemic. Decide how and how much you should be paid for telecare? The time it takes to read, research and respond to emails and chart messages, as well as to analyze remote monitoring data can be all-consuming. Doing everything yourself could lead to burnout. It’s important to develop a strict protocol for telecare. For instance, you can insist on a specific format and limit the amount of words in direct messages. Fees are also not out of the question. Cleveland Clinic started billing patients’ insurance companies for messages requiring at least five minutes of health care providers’ time to answer. Sending messages could cost as much as $50 per message, depending on the time and skill necessary to answer the request.

Set behavioral and attendance expectations

1. Many doctors have reported that telemedicine patients sometimes log in while driving, shopping and even on the toilet. It’s important to establish parameters in advance, such as insisting they are fully present and in a quiet environment. 2. A 15- to 20-minute telemedicine session is almost pointless when it takes five to ten minutes for the patient to log in. Establish the expectation of arriving early. If the patient misses an appointment, consider charging the copay at the time of making the appointment to better ensure the patient is there. 3. Set expectations for yourself as well. Be prompt, smile on screen, dress professionally, and remember to engage with the patient and be empathetic. During the visit, make sure your background is clean and presentable. At the end of the visit, summarize with key takeaways. Try recording yourself in advance, then adjust the lighting and camera angle. Telehealth has become an integral part of mainstream healthcare. Of course it’s possible to resist, and if you’ve heard the horror stories, you might even think it’s not your cup of tea. If that’s the case, there is always the option of partnering with telehealth-only providers. But if you’re interested in expanding your practice to include telehealth, be mindful of what’s best for you, and stick to it.