Getting Started With Telemedicine

Telemedicine will play a significant role in contemporary urology and nephrology practices. Although only a small percentage of urologists and nephrologists current use telemedicine, many more practices are going to embrace it in the near future.

Whether they know it or not, most urologists and nephrologists have practiced a form of telemedicine in the past, such as by taking phone calls from patients asking for medication refills. In these cases, physicians have either acquiesced and called pharmacies to refill the medications or denied the requests and suggested to patients that they make an appointment and receive a new prescription. The latter action might not have endeared patients to a physician. Physicians who acquiesce to patients’ phone requests to have prescriptions filled or other seek free medical advice should keep in mind that they are not being compensated for providing those services. At the same time, they are legally responsible for their actions and encouraging patients to continue to seek free medical advice without making follow-up appointments. These consequences do not make for good medicine. That is where telemedicine can be an important adjunct to a practice. Physicians can be compensated for their phone or video interaction with patients while practicing good medicine, as now there would be a record of phone interactions. This article will discuss the process for implementing telemedicine into a practice with minimal time, energy, effort, and expense. It also will examine some legal issues associated with telemedicine.

Easy to implement

Practices typically use telemedicine platforms to manage one or both types of encounters: walk-in visits through the practice’s website in which patients do not care which doctor they see, but are only looking for the first available provider; and appointment-based consultations, whereby patients schedule video chats in advance, usually with a specific doctor. Although incorporating telemedicine into a practice may seem overwhelming, it is not as challenging as implementing an electronic medical record (EMR) system, as this requires training, buying expensive hardware and software, and the anticipation that production will be decreased until doctors, staff, and patients are comfortable with the new method of providing medical care. Telemedicine, however, is easy to implement, requires minimal additional equipment, will be able to interface a practice’s website and EMR system, and will increase, not decrease, productivity and work flow. Patients will appreciate the option of not having to travel for an appointment.

Most patients and referring doctors are already comfortable with their mobile phones and their digital devices such as iPads, social media, and wearable technology, such as Fitbits. So now is an opportune time to implement a telemedicine service. It is not a question if physicians will embrace telemedicine, but when they will include it as communication tool. 

Getting Started

Physicians and their colleagues and staff first need to become comfortable with telemedicine technology. Physicians can begin by using video communication throughout their practice, such as by hosting the next staff meeting using video, and engaging in video calls with family and friends. They should practice starting and ending calls, adjusting audio volume and video, and inviting others onto their platform. Without developing confidence in using video technology, physicians will not be able to use it effectively with patients.

To be sure, gaining confidence in front of a camera will involve a learning curve. I have experienced the nervousness and anxiety when creating a video for my practice. I had a 5-minute presentation for patients on a urologic topic and I practiced several times trying to be at ease speaking with no audience or no patient to receive my message.  I thought I was okay with the presentation until the iPhone camera or the computer camera was turned on. Stage fright ensued, and I had to make the presentation multiple times until it appeared reasonably natural. It was only after making 10 to 12 videos that I became comfortable in front of the camera. I am sure this would be the case with other physicians.

[For samples of my YouTube videos, nearly 100 examples, go to YouTube.com.  Type in Neil Baum MD, https://www.youtube.com/results?search_query=neil+baum+m.d.+urology+]

Figure 1. Telemedicine Video Conferencing Product Reviews

Companies	Pros	Cons
Google+ Hangout	Free	No screen sharing
SecureVideo	HIPAA compliant, Good technical support	No H.323/SIP support
Skype	Market Leader for voice and video	No screen sharing Requires ample bandwidth
Tango	Excellent on iPhone, Android	No screen sharing
WebEx	Leader for presentation\webinars	Decrease video performance
Zoom	Mobile support iPad, iPhone, Android	Group video not free after 40 minutes
CiscoJabber	Supported on all mobile devices (iPad, iPhone, Blackberry, Android)	Complicated server requirements and difficult to cross firewalls

Figure 2. Best telemedicine apps

• MDLine
• Lemonaid
• AMWell
• Babylon
• Dialog
• TalkSpace
• FirstOpinion
• SimpleContacts
• PlushCare
• Maple
• Pager
• Doctor on Demand
• HealthTap

Selecting a video platform

I am not a video expert, but Figure 1 provides a list of the most popular video providers and the advantages and disadvantages of each, and Figure 2 shows a list of free video chat apps. Apps are available that can:

• easily share and mark up lab tests, MRIs, other medical documents without exposing the entire desktop
• securely send documents over a HIPAA compliant video
• stream digital device images live while still seeing patients’ faces 

Some practices rush into telemedicine even though their computers do not even have cameras! Physicians need to take their time, do research, and test out a few programs before selecting one for their practice. They should make sure their implementation team has the necessary equipment, including webcams, microphones, and speakers.

Practices might consider appointing a telemedicine tech point person who is knowledgeable about the new technology and can patiently explain it to others. Physicians need to keep in mind that video chat is depends on Internet connections and if there is sufficient bandwidth, meaning an Internet connection that is speedy enough to carry the bulk of video frames in high quality.

 If a practice has connectivity problems, physicians should consider hiring or using an IT resource to ensure that all devices work properly. 

Telemedicine laws

Each state has different rules regarding telemedicine, so physicians need to find out the rules that apply to them. In certain states, physicians are required to “establish a patient-provider relationship” in-person before they can start counseling or treating them via telemedicine. It is best to start TUN with existing patients. Physicians should check whether they practice in one of the 26 states that require an informed consent form signed by patients.

[See the following website for state telehealth and reimbursement policies for each state.  https://www.cchpca.org/sites/default/files/2019-05/cchp_report_MASTER_spring_2019_FINAL.pdf]

Once a team is comfortable using video throughout a practice, it is time to test it out with a few patients and perhaps a few payers. Most patients are eager to start using video for their medical encounters. Survey research and years of experience have shown that downloading an app is no barrier to adoption. Even if physicians serve a senior population, they may be surprised at how willing they are to have consults via video. According to a recent survey by American Well, 64% of patients are willing to see a doctor over video. 

[For more information on telehealth for Medicare patients see: https://static.americanwell.com/app/uploads/2019/05/Telehealth-for-Medicare-Advantage.pdf]

Furthermore, physician colleagues, medical assistants, and nurse practitioners will need some basic troubleshooting skills. They should be prepared to make video connections seamless for patients. Usually, existing patients just need some guidance and encouragement, such as telling them to check their spam folder for their invites if the invites failed to arrive in their email inbox, adjusting the audio settings, or setting up a webcam. In the beginning, physicians at the very least should make sure they build in plenty of buffer time for the unexpected.

Physicians should observe and collect patient feedback regarding such questions as:

• What kinds of devices (laptop, mobile) do they prefer using?
• What kind of networks are they using (3G, corporate, home)
• What questions do patients ask?
• What features do they like? What features do they have a hard time finding?
• What do they like or not like about the video experience?

The take home message is that physicians must have patience in the beginning and be willing to hold patients’ hands as they get acclimated to video consultation.

Virtual waiting room

Armed with feedback from patients’ video experience, it is time to start streamlining online workflow. A stand-alone video chat app may meet ones needs, but most practices want to be able to manage video visits similar to the way they manage face-to-face visits with patients. This may mean trying out a virtual waiting room. A virtual waiting room is a simple web page or link that can be sent to patients. On that page, patients simply sign in with minimal demographic information and select one of the time slots when the doctor is available. Typically, these programs are designed to alert doctors and/or staff when a patient enters the virtual waiting room. Patients have access to the online patient queue and can start a chat or video call when ready. Such a waiting room model serves as a stepping stone for new practices to familiarize themselves with video chat. This approach is perfect for practices that already have a practice management system and just want to add a simple video component.

Bottom line

Patient-driven care is the future, and video telemedicine will be part of it. Patients want to have ready access to their health care providers without having to spend hours for a medical encounter that could be done in a few minutes via video. It is now time to make the leap to video telemedicine. In the next article, I will discuss the path to compensation.