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.
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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
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.
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.
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
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:
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.
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
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.
Key questions to consider when trying to implement a telehealth program:
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.
Listeners will describe the state and future of telehealth and explore ways to implement it in their practice.
After listening to this episode listeners will…
Dr. López reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Dr. López: The Man with the Broken Fingers by Carl Sandburg
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I appreciated the discussion on this topic, and along with our training (TMS) at the VA, think the transition to using this form of visit will be reasonably straightforward. As you know, our VA patients come from a much larger area than typical primary care clinics, sometimes 2-3 hour drive or more. Telemedicine should help us provide better access, though it may not meet certain emotional needs of some veterans who view there access to a place where veterans congregate and have person access to “their” health care system. Question: Are there any different or unique medical-legal concerns in providing these types of visits? It has been said that during a patient-doctor visit there is a third entity present, a medical liability attorney. Thoughts? I enjoy your podcasts and frequently recommend them to colleagues. Thank you.