An internet television program that explores the intersection of medicine and the law.

Physician Focus: Telemedicine

By Jonathan Terry, DO, ABIHM to Telemedicine

Description

Physician Focus: Telemedicine

Our guest on Healthcare Matters is Jonathan Terry, DO, ABIHM, an osteopathic physician/surgeon and psychiatrist who uses telemedicine extensively in his practice. Dr. Terry practices at the United Health Centers of San Joaquin Valley, which recently won the 2016 Health Delivery, Quality and Transformation Award from the American Telemedicine Association.Dr. Terry's practice focuses on serving rural and migrant patients in California, who would have difficulty in accessing comparable services if it weren't for telemedicine. In this series, we discuss many aspects of telemedicine with Dr. Terry, including defining the types of services available through telemedicine, the benefits telemedicine can have for both patients and doctors, and the business aspects of telemedicine, such as informed consent in telemedicine, physician reimbursement rates and much more. This is the full interview with Dr. Terry. For easier viewing, we have also created a video (links below) for each question we asked Dr. Terry.

  1. Defining Telemedicine
  2. Ways the Affordable Care Act Affects Telemedicine
  3. Four Advantages of Telemedicine
  4. Informed Consent and Telemedicine
  5. Electronic Medical Records and Documentation in Telemedicine
  6. Legislative Challenges to Telemedicine
  7. Telemedicine Reimbursement Rates
  8. Physician Focus: Telemedicine

Transcript

Mike Matray: You’re a proponent of telemedicine, and I was hoping we could begin by defining the practice of telemedicine.

Dr. Terry: That would be great Mike. Really good question to start. You know for definitions I always like to go with the American Telemedicine Association, or the ATA, which is recognized as one of the leading groups as an advocate and resource for those of us who do telemedicine. How does the ATA define telemedicine? They keep it pretty broad. They say that telemedicine is the use of medical information that’s exchanged from one site to another by any electronic communication involved with patient care. What does this mean in practice? Well, this can include video consultation, kind of like the video conversation we’re having right now. It can be transmission of still images in what we call store and forward, which has been great for dermatology, for radiology, things like that. It also includes E-health. Things like patient portals that many of us participate in, and even remote diagnostics. The opportunities to use technology to say, listen to a patient’s heartbeat or conduct vital signs across a distance.

Mike Matray: Telemedicine has been around for a while, but we’re currently in a period where the healthcare delivery system is going through a rapid change because of the Affordable Care Act of 2010. How has the Affordable Care Act benefited, or hindered the practice of telemedicine?

Dr. Terry:  Mike, you know overwhelmingly the Affordable Care Act of 2010 has been really just wonderful for telemedicine. It specifically outlines that the center for Medicare and Medicaid innovation, or CMI is able to develop these new care models that are focused on technology. There’s also some funding and direction for studies in telehealth utilization, especially in behavioral health. It requires the accountable care organizations to enable different technological focci. There’s so many different advantages really, for patient access and for providers. For Medicaid recipients specifically, one of the best advances comes in the area of home health and chronic conditions, which really expands the topic of in-home consultation services for patients who might not have the ability to seek in-person services for any number of reasons.

Mike Matray: That obviously seems like a definite advantage for somebody who is home bound. What are some of the other advantages of telemedicine to both the patient and the physician, and in what situations are these advantages more pronounced?

Dr. Terry: Really great questions Mike. Of course, we wouldn’t be doing telemedicine if there weren’t significant advantages for both patient and provider. For starters, when I train my staff on the technology, I’ll tell them in general about the acceptance. Some might be fearful, you know, that the patient doesn’t want to be seen over the t.v., something like that. And I’ll site several studies showing that patients who see the doctor over telemedicine as opposed to the same doctor in a face-to-face study will perceive that provider as being first more knowledgeable and second as having spent more time with the patient, which I think are two great things for our fragmented healthcare system.

One of my favorite things though, that I have to say about telemedicine, really, and the main reason that I use it in my practice is for improved access. It can of course expand the reach of our providers beyond the walls of the clinic, beyond the walls of the hospital, bring healthcare to the home, to the school, to the rural community, to the islands, to international recipients, things we couldn’t do before. In my own experience I do consultation psychiatry for a migrant health center and a federally qualified health center that covers three counties in rural, central California. In one day Mike, I might see patients across 13 clinics in a nearly 200 mile area all without leaving my office. Every single one of these patients is somebody who comes from an underserved background who would have just tremendous difficulty in having the same sort of access with a local provider.

On a similar note, I would mention, you know, telemedicine is highly cost-effective. There are several studies that point at reduced healthcare costs, something we’re all concerned about, through adoption of telemedicine and the efficiency that comes with it. The neat thing about this is while each state requires sort of specific technology for telemedicine, now we’re doing it with our tablets, and with mobile phones. There are a number of clinics that are doing – just using secure software that way.

And with telemedicine of course a third thing that that I might mention is it’s reasonable to believe we might be accepting convenience in exchange for some sacrifice in quality. And, I think that’s a valid concern, but the data just doesn’t show it. It’s interesting, it shows the exact opposite. In many disciplines telemedicine has actually been shown to offer a better product higher patient satisfaction and similar, if not better outcomes.

The last thing I might mention, and I know there’s a lot to say about this question, is patient demand. And, you know, I think about this in terms of we can now stream new release movies in our homes, we can have packages delivered the next day, so I think a lot of our consumers are saying – why do I have to go to the clinic and take time off work to go to the doctor’s office? So telemedicine, of course, has its role in highly underserved communities, but maybe even in our urban environments, for the working customer, patients, families, communities, even employers are really figuring out, ok, how can we make this technology work for us, to make healthcare more accessible?

Mike Matray: One of the most important elements of ethical care is to get informed consent from your patient prior to beginning any course of treatment. Is it more difficult to achieve informed consent via telemedicine setting than a traditional office setting? If so how should a physician practicing telemedicine alter his or her approach to achieving informed consent?

Dr. Terry: You know Mike, informed consent is something we think a lot about with telemedicine. I think it’s easiest if we look at getting informed consent for telemedicine in a similar way that we’d look at it for any other procedure. What I mean by this is that there’s a precedent for having a separate consent form or an electronic form specifically off the rise in the use of telemedicine. Usually this form will outline the risks and benefits specifically of telemedicine, and specifically say that the patient has the right, of course, to decline telemedicine at any time. It’s also I think, a good idea as we’re using electronic methods to have some type of privacy policy stating specifically how’s this information going to be used, how will it be transmitted, maybe how will it be stored as well as any potential security breaches that might be inherent to the software or the transmission.

Mike Matray: You were talking about an electronic informed consent form, and I assume that would be filed away in the electronic medical record. How do best practices for entering data into a medical record when it’s acquired via telemedicine as opposed to face-to-face encounter differ?

Dr. Terry: You know documentation with telemedicine, even though in some ways we’re taking short cuts a long distance, that sort of thing, documentation is certainly something we can’t take any short cuts with. Best practices for telemedicine include documenting not only that the practice occurred of course by telemedicine, but also in many sort of third party payer situations, why was telemedicine used? Commonly this might be because of no local provider being available. Today if you want the service, this is the way we’re offering it.

It’s also a good idea to document each encounter of course that the patient has renewed essentially their informed consent to telemedicine, and that the provider or staff have explained the risks and limitations of the process of telemedicine itself. Many medical records of course now allow for electronic submission of our charges, of our ICD-10 diagnoses and CPT codes, and there may be additional procedure codes as well that should be documented and entered at both the origination, usually where the patient is at and the receiving, where the provider is at, sites.

Mike Matray: One of the greatest challenges in rural communities is access to healthcare. What advantages does telemedicine offer in treating these under-served populations in the United States? Also, Texas, one of the largest states in the country, and one of the largest rural communities recently made it more difficult to practice telemedicine. They no longer allow doctor/patient relationship unless the patient and doctor meet face-to-face initially. How do you feel about that sort of regulation?

Dr. Terry: Yeah Mike, and you know maybe I’ll start with the regulation in Texas, talking about the face-to-face encounter, and specifically what they’re look at there is the presence of a physical exam that should be done at the first visit. That’s something that I know the American Telemedicine Association is looking at actively as many states do not require this. It’s interesting, because if you think about many specialties, think of the radiologists, the pathologists, the dermatologists. So many of these services are being conducted flawlessly without the use of a physical exam already. I think that this is one of the areas that’s very interesting, very innovative in the law that we’re seeing right now.

My expectation is that eventually what we’re going to see as, you know looking at 2015 with over 200 laws passed in the United States just related to telemedicine, it’s such a rapidly evolving field and so I think we’re going to see the pendulum swing a little bit between more conservative thinking and more progressive approaches, especially as we look at our nation’s needs for expanding services.

Mike Matray: You had mentioned that more than 200 laws were passed in relation to telemedicine last year. What are some of the highlights? What are the great advances, and what are the great hindrances that might have come out of 2015?

Dr. Terry: 2015 was a really neat year. I think that one of the biggest things that we’re seeing is just innovation across the field, Mike. We’re seeing companies that are putting a doctor in people’s smart phones, the ability to text message a doctor who could be anywhere. We’re seeing opportunities even on the web for companies, for patients to directly communicate with say a third party dermatology service, to upload a picture of that scary mole and get an opinion on it, or maybe you do need to go in and get a biopsy or something, which may not always be the case.

The laws lag a little bit behind. The neatest thing … I think the best highlight that we’re seeing is that the case laws tend to be overwhelmingly progressive. They tend to be expanding telehealth, looking at ways that how else can we safely use this technology? The incidences that I see of say physicians getting in trouble is when sort of … The same things that we see them getting in trouble for in person when they’re practicing unsafely or outside of their scope of practice.

Mike Matray: As our viewers understand, medicine is both a business and an art. How does the reimbursement rate, the business side vary from a telemedicine visit to a traditional doctor’s office visit?

Dr. Terry: You know Mike, I’m glad you asked that question. I think out of everything that we’ve talked about so far today, the reimbursement rate sort of remains one of the stickiest issues in telemedicine. It’s something that I do think is going to be worked out significantly in our professional careers, but it can vary a lot depending on the payer.

Medicare is especially interesting as it has so man limitations on facility location and eligibility, what services might be eligible for telemedicine, which providers can see a patient, and how claims are submitted. There’s actually a great summary of this, refer to the American Telemedicine Association on their website, just kind of outlining the Medicare laws. Interestingly state Medicaid programs in general have had far less restrictions, but of course this will vary state by state. Commercial insurers kind of opens up its own box of worms as each commercial payer might have its own set of limitations.

While I can’t necessarily speak in sort of broad conclusions about reimbursement, I will say that sort of each situation requires a bit of background research, starting with the patient, starting with the payer, but certainly for health groups that are located or work primarily with a certain team of third party payers. It would be easy to look at sort of say, your top five payers and see how do they incorporate telemedicine, and what’s accepted.

Mike Matray: Excellent. Well that was a fascinating discussion of telemedicine and both it’s history and what we can expect in the future. Thank you for your time, Dr. Terry.

Dr. Terry: My pleasure Mike. Thanks so much for having me on board.