Telehealth with Ana María López MD

May 2, 2019 | By Matthew Watto, MD

Untangling the future of telehealth and how to get there

Electric cars, virtual reality, nanotechnology, and now… telemedicine? We chat with Dr. Ana María López MD, FACP about the future of telehealth, how to implement it in your practice, and the challenges you might face in doing so. Dr. López is immediate past president of the American College of Physicians (ACP) as well as Vice Chair of Medical Oncology and Chief of New Jersey Division Sidney Kimmel Cancer Center of Thomas Jefferson University. Her main areas of professional interest and expertise include cancer prevention and equity, integrative oncology, implementation of innovations in health care including telemedicine, and women’s health. We learned immensely from our talk with her and we hope you will, too! ACP members can claim free CME & MOC credit at https://acponline.org/curbsiders. Download Dr Brigham’s telehealth cheat sheet as a PDF.

Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and produced by: Hannah Abrams, Stuart Brigham MD

Cohosts: Matt Watto MD, Stuart Brigham MD, Paul Williams MD, Hannah Abrams

Guest: Ana María López MD

Time Stamps

• 00:00 Disclaimer, intro and guest bio
• 04:20 Guest one line, poetry recommendations, favorite failure
• 12:00 Defining telemedicine
• 14:12 What kind of services exist in telemedicine? How can the technology make your practice easier?
• 20:18 Is there good evidence for telehealth and telemedicine?
• 24:20 Concerns about telehealth and the loss of touch as part of the doctor-patient relationship; haptics and the remote physical exam
• 30:17 Providing telehealth across state lines
• 34:35 Consultation codes for telehealth and ECHO (remote consultations)
• 40:20 Basic steps and best practices to start implementing telehealth
• 44:30 Stuart’s shares some preliminary data on use of telehealth and workforce satisfaction
• 49:12 Adding access by using telehealth in primary care
• 51:40 Take home points
• 54:42 Stuart shares a pun

Telehealth Pearls

Telemedicine is a translational science. Any and all aspects of medical care (eg history taking, patient education and even physical exam) can become a ‘tele-’ aspect of care by working with engineers; the frontier of telehealth lies in clinicians looking for ways that it could improve their daily practice.

Don’t be surprised if specialist referrals decrease after an initial boom– in one example Dr. López shared, specialty referrals decreased after primary care offices learned how tele-consultants would counsel and manage more straightforward patients and only referred more complex patients.

The technology is a tool. Communication is still key, and with consistent formatting and planning, you can get much of the same information.

New guidance from CMS may alleviate some questions about coding and billing for telemedicine, both in specialty consultant and consulting roles (download Dr Brigham’s telehealth cheat sheet (see link above)).

If you are trying to start out with telemedicine, think about how being able to see your patients remotely might help your day to day practice, and choose “easy wins” to start familiarizing yourself and your patients with the technology.

Think of telemedicine as “bringing back the house call;” it allows us to be with our patients virtually when and where they need us.

Telehealth In-Depth Show Notes

Defining Telemedicine

Telemedicine is the use of electronic information and communications technologies to facilitate access to health care. Telecommunications technology can include everything from telephone and internet e-visits to immersive technology that recreates almost all aspects of an in-person visit and patient and provider education. Institute of Medicine 2012

Examples of disease-specific bundled telemedicine services include diabetes care with tele-nutrition education, tele-podiatry, tele-retinal screening, and tele-consult to endocrinology; heart failure care with tele-auscultation and tele-echo; and generalized anxiety disorder care with tele-psychiatry.

A key requirement for telemedicine, per the ACP’s Ethics Manual: Seventh Edition (2019), is establishment of a patient-physician relationship.

The Future: a Hospital Without Walls

Many of the telemedicine innovations being implemented are almost 10 years old already; more advanced technology is already coming in the pipeline. Upcoming telemedicine ideas include ‘smart rooms’ that can monitor vitals and ‘smart floors’ that can anticipate and detect falls in at-risk patients. Karunanithi Ex Rev Med Devices 2007

One key promise of telemedicine is the concept of a ‘Hospital Without Walls’: allowing patients to spend more of their recovery time at home, but with telehealth monitoring to provide the follow-up and tracking capacity of a hospital. Haux Stud Health Tech Inform 2016

What’s the Data Say?

Current evidence varies by intervention, but telemedicine approaches are often comparable to traditional approaches and have demonstrated patient satisfaction across a wide range of specialties. Brown-Connolly J Telemed Telecare 2002

In order to conduct more research on telemedicine, Dr. López sees two key questions:

1. What are the inter-rater reliability, test characteristics, and evidence for the physical exams maneuvers we already do in-person?
2. What is the right metric to measure a telemedicine intervention– a process metric, diagnostic sensitivity, or patient outcomes?

Working with Telemedicine Technology

Dr. López’s tips for working with remote technology:

Script out the physical exam you need to conduct via the telemedicine technology. Make sure you and your consulting physicians or telemedicine coordinator have a standardized format for presenting and examining patients with the technology to improve your reliability.

Don’t leave the patient alone; a coordinator present will immensely help facilitate the process and prevent miscommunication. A key exception is telepsychiatry.

Remember that the technology is only a tool; it’s how you use it that will determine your connection with the patient. Position cameras such that you can consistently look at the camera/patient.

Challenges for Telemedicine Implementation

Interstate licensure:  

At the present time, you will need to be licensed in the state that you are providing telehealth services.  There are services to assist with the paperwork of licensing for telemedicine in multiple states, but licensure still presents a significant barrier for interstate use of telemedicine. Policies vary by state. Weinstein, et. al American Journal of Medicine 2014

Coding:

In November 2018, CMS released guidance about the use of inter-professional consultation codes 99446-99449 and 99451-99452 for telemedicine. These codes allow for more interprofessional consultation.  “Virtual check-in” (HCPCS G2012) allows for a brief patient telephone call, but is limited to the billing healthcare professional. Both consulting and consulted providers can use the different (99451 or 99452) codes to bill for consultations. Download Dr Brigham’s telehealth cheat sheet.

Getting Started in Telehealth

Key questions to consider when trying to implement a telehealth program:

1. What is available in your setting?
2. What would be able to interface with your EHR?
3. What would be helpful to your patients?

Dr. López’s advice: Don’t try to do too much to start. Choose ‘early wins’, or focused programs that are easy to setup. Build your familiarity (and your patients’ familiarity) with the technology. Connecting patients to existing wellness education services like nutrition or exercise classes through telemedicine is another method to build familiarity.

Take-home points

1. Telemedicine can be a key part of team-based care, prevention, and early detection as the population grows and patients become more complex.
2. Telemedicine can allow us to be there with patients where and when they need us; it can reduce both “dollars and cents” cost of disease but also burden on patients.

Goals and Learning Objectives

Goals

Listeners will describe the state and future of telehealth and explore ways to implement it in their practice.

Learning objectives:

After listening to this episode listeners will…

1. Describe the current state of telemedicine technology and policy
2. Identify strategies for implementing telemedicine within their practices
3. List the current services available and data for telemedicine
4. Learn an approach for explaining telemedicine consultation to patients
5. Learn best practices for successful telemedicine consultations

Disclosures

Dr. López reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Recommendations:

Dr. López: The Man with the Broken Fingers by Carl Sandburg

Links from the show are included above.

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