Remote Care: How to Use Telemedicine
Larry Greenbaum, MD
Telemedicine, the use of electronic communication to provide health care, has been relatively slow to catch on in some places, but many physicians who have incorporated telemedicine into their practice believe it can be advantageous.
It helps provide regular care to people in remote areas, saves time for patients and providers, and increases efficiency. In interviews with Renal & Urology News, two doctors share their experience with telemedicine.
Children's Healthcare of Atlanta (CHOA) has had enough success using telemedicine that it is continuously expanding the service, said Larry Greenbaum, MD, PhD, the hospital's chief of pediatric nephrology. The hospital has an internal “hub” that connects to a network of sites funded and equipped by the Georgia Partnership of Telehealth.
These sites are set up in rural areas, allowing patients to connect with distant doctors. Nephrologists affiliated with CHOA use the technology for outpatients. At each remote site, there is a “presenter,” which might be a nurse or physician assistant, who performs a routine physical exam that the physician can see and hear with specially equipped stethoscopes, otoscopes, and ophthalmoscopes. The only part of the physical exam that cannot be easily transmitted is palpation of the abdomen.
Dr. Greenbaum said the technology provides access for families that might not be able to travel to Atlanta. Patients and parents do not need to miss a full day of school and work, respectively. It also allows them to monitor rural patients more frequently. “We can communicate by phone, but it's just not the same as this kind of interaction,” he said.
Accessing a doctor when there is not one on hand is the main reason the Brody School of Medicine at East Carolina University in Greenville uses the technology. Tejas Desai, MD, Assistant Program Director for the university's internal medicine residency program, said it allows doctors to be “in different places at the same time.”
Physicians, pharmacists, and residents all have either iPhones or iPads with cameras. If clinicians are with a patient and they need to connect with Dr. Desai or another senior-level physician, they use FaceTime, which connects the two parties via video.
“We don't use it as a way to eliminate us from the room. We use it so when someone junior is there, he or she can talk with me,” he said. “We can see more people in a faster amount of time and give them the feeling they have been taken care of.”
He uses it for talking with patients in a dialysis unit, lab follow ups, seeing a patient at home, summarizing information for family members, and to see a patient who cannot easily be moved. He also communicates with patients via e-mail so they use an office visit for more important things like a yearly physical.
Reimbursement is one of the biggest challenges of telemedicine. A handful of states including California, Louisiana, Texas, Oklahoma, and Kentucky mandate reimbursement by private insurance for telehealth services. The reimbursement rates may vary and aren't always equivalent to an in-person meeting.
Medicaid reimburses for telemedicine in many states. Medicare reimburses for services such as outpatient visits, nutritional counseling, kidney disease education, medication management and end-stage renal disease-related services—but only for rural patients.
Another disadvantage, according to Dr. Greenbaum, is the imperfect physical exam. If clinicians suspect problems, they have to make sure the patient gets a hands-on exam by another physician.
Telemedicine should be avoided when patients have emergency needs, Dr. Desai said. It also should not be used for “really bad news” or as a replacement for a daily face-to-face visit with hospitalized patients.
It might be helpful to speak with someone with experience using telemedicine prior to implementing a telemedicine program, said Dr. Desai, who offers the following advice:
- Document all e-mails in a patient's health record. Video conferences can also be recorded, saved, and uploaded into their record.
- Only allow video conferencing from 9 a.m. to 5 p.m. No one wants to talk to a patient or other doctor while wearing sweats with kids in the background.
- Require patients to initiate communication and agree to check it afterward for his response. Patients should be informed that serious issues should be handled by telephone and that their e-mail will not be answered on weekends.
Drs. Desai and Greenbaum do not recommend using programs like Skype for patient visits. The image quality isn't great and there is no reimbursement for it (because there is no physical exam), Dr. Greenbaum said.
Dr. Greenbaum said he and his colleagues are fortunate to have the infrastructure they do. “I think it obviously makes sense with what I'm doing – outpatient visits with patients coming from a significant distance,” he said. “For people who have a practice that has a wide geographic coverage area it works really nicely.”
The Telehealth Resources Center provides a wealth of information on everything from training to staffing and legal issues to reimbursement information on here.
A Medicare reimbursement checklist for telehealth professional fees can be found here. The document highlights requirements for Medicare reimbursement, the services that are covered and their codes.