How to Become a Telehealth Doctor

There's no question that telehealth holds great promise. The ability to monitor patients remotely not only lowers the cost of providing care, but also expands access to medical services critical for the chronically ill and those who reside in underserved communities. Indeed, telehealth solutions that connect patients and providers in separate locations are touted by many as the magic bullet to the looming shortage of primary-care physicians, which is likely to worsen as millions of previously uninsured Americans obtain coverage under the Affordable Care Act.

Demand for digital medicine has been fueled, in part, by the aging population, which increasingly requires home-health services, and by corporate America, which favors any technology that can replace a two-hour doctor's office visit with a 10-minute phone or video consult, thus reducing employee absenteeism. According to information and analytics firm IHS, revenue for telehealth devices and services in the United States is expected to reach $1.9 billion by 2018, up from $240 million in 2013.

Most early adopters have been large hospital systems and medical groups, but Robert Wergin, president-elect of the American Academy of Family Physicians, says smaller practices are beginning to embrace the concept of remote clinical care, as well. "It's increasingly on their radar screen," he says, noting the proliferation of urgent care clinics have compelled private practices to cater more to patients' needs. "A big issue for small practices is utilizing staff more effectively through team-based care and providing services in a more convenient setting. Telemedicine is part of that."

An effective telehealth program, however, does not take root on its own. Practices that hope to improve patient outcomes and enhance revenue streams must ensure their IT infrastructure and staffing ratios are sufficient to support electronic encounters, says Wergin.  They must also take steps to protect patient privacy, comply with state licensure requirements, and structure payer contracts so that electronic consultations are fairly reimbursed, he adds.

Telehealth expands upon telemedicine, the first iteration of remote healthcare, which focused exclusively on curing patients. It encompasses a broader spectrum of care delivery, including preventative (health education), promotive (disease management), and curative (diagnosis and treatment). Technologies that enable virtual visits include the Internet, videoconferencing software, streaming media, still image transfers, and mobile communication devices such as smartphones and tablets. Used properly, such tools could save the national healthcare system billions of dollars per year, according to the Kauffman Foundation, which estimates that remote patient monitoring for heart disease, diabetes, pulmonary disease, and skin disease alone could save $197 billion nationwide over 25 years.

Many private practices have already dipped their toes into the telehealth waters with the implementation of patient portals that meet the "meaningful use" requirement for federal incentive checks. Such portals generally allow patients to schedule appointments, access their medical records, pay bills, review lab results and X-rays, request prescription refills, and communicate with providers via e-mail.

Alan Dappen, a primary-care physician with DocTalker Family Medicine in Vienna, Va., is among them. Launched 10 years ago, his full-service practice offers face-to-face office visits, e-mail encounters, house calls, and phone consults. The Web-based portal he developed gives patients the tools to play a more active role in their own healthcare, and connect with his team of providers where and when they choose. "When we started this practice, we decided that telemedicine was a critical component," he says, noting 50 percent of his patient encounters today are conducted via phone. "E-mails are good, especially if you have a non-urgent request to call in medication, for example, but they can also be time consuming. It's faster and better for me to communicate with most of my patients by phone."

Determine need

Practices implementing a telehealth program of their own should first conduct a needs assessment, according to the Health Information Technology and Quality Improvement (HITQI) agency. Determine what access exists in your community to specialists or tertiary care and whether your practice owns an expensive piece of equipment that is underutilized, like a CT scanner that could be used for teleradiology. Gauge, too, how willing local physicians are to refer their patients to a telemedicine service. Potential patient demand can be measured by examining your claims history to determine the number of patients with conditions that can be addressed remotely.

Telehealth programs benefit from economies of scale, so look, too, for programs that already exist in your state, the HITQI recommends. Hospitals, independent physician organizations, or accountable care organizations with which you are aligned may already have a program in place. Wergin adds many smaller practices, including his own, are exploring the cost-effective strategy of tying into the telemedicine program available through their local hospitals.

Assess the technology

Telehealth sessions can be either synchronous, including real-time videoconferencing between patient and provider, or asynchronous, which is sometimes referred to as store-and-forward. In asynchronous sessions, data such as digital images, audio clips, and video clips are captured locally and stored for transfer at a later date - often through a secure Web server, encrypted e-mail, or EHR. The consulting physician can review the data and make diagnostic, treatment, and planning recommendations to the referring provider, according to the American Health Information Management Association.

You need not spend a fortune on high-tech gadgetry, however, to launch a telehealth program, says Dappen. A webcam, smartphone, and high-speed Internet line should suffice. The pivotal piece of the puzzle is that all Internet connections must be encrypted to ensure HIPAA-compliant data transmissions. For that, you may require outside expertise. Fortunately, resources abound. Most professional organizations have task forces and guidelines to help members deploy telemedicine solutions, while federally funded telemedicine resource centers, including the Great Plains Telehealth Resource & Assistance Center http://www.gptrac.org/ and the Northeast Telehealth Resource Center http://netrc.org/, exist regionally for the sole purpose of consulting with providers on developing telemedicine programs.

Large broadband networks, such as the California Telehealth Network or the Colorado Regional Health Information Network, also provide dedicated circuits for network users, according to the Center for Connected Health Policy. These networks deliver secure, private data transmission, ensure quality of service, and prioritize emergency medical communications. Members also receive discounts to private consultants that specialize in remote patient monitoring, technology set up, and staff training.

There are also full-service telehealth providers, including American Well and Teledoc, that provide HIPAA-compliant software for secure voice and video transmissions through your practice website. The software enables providers to document patient visits, submit electronic claims, and conduct physician-to-physician consults as well as patient services.  Such companies offer a network of certified clinicians who are available around-the-clock including weekends to bridge the after-hours gap.

Paul Preslar, a family doctor in Midwest City, Okla., deployed American Well's software three years ago when he launched dashndoc.com, a solo virtual telehealth practice designed to complement his brick and mortar office. After an initial face-to-face visit, Preslar says patients who create a dashndoc profile can conduct virtual office visits by iPhone or iPad for a $45 cash payment. "With copays for insurance now reaching $30 to $40, a $45 cash visit in which they don't need to leave their home or office becomes very cost effective," he says. "Some patients can't afford to take off work, but they can conduct a telemedicine visit to check on a skin rash, or hold up their phone so we can look down their throats with a webcam to get a high definition picture." Easy access, he notes, keeps chronically ill patients in closer contact with his office, and increases the likelihood that patients will be seen for follow-up exams, both of which help reduce hospital readmissions and improve patient outcomes.

Consider staffing

A successful telehealth program must also include a trained team of sufficient size and skill to deliver service in a high-quality and consistent manner, according to the Telehealth Resource Centers. Practices that offer digital medicine should designate a trained clinician to monitor and interpret the transmissions received from at-home and other remote measurement devices. "You have to look at what policies you need to make sure that as patients enter your Web-based portal they are being funneled through the system effectively," says Wergin. "How are patients going to be triaged?"

Operating protocols should also clearly define the actions clinical and clerical staff should take before, during, and after a telehealth encounter, including documentation, scheduling procedures, patient information that must be obtained prior to the consult, the process for billing, and the manner in which your practice reports consultations to any referring physicians, according to the Telehealth Resource Centers.

If you opt not to use a telehealth service, and you plan to provide extended hours, you may need to hire more staff to cover nights and weekends. Better yet, use what you have more effectively. Dappen says he offers 24/7 access to the five providers on his team while keeping overhead minimal through the use of creative scheduling. "We have five clinicians and two staffers in an office with three exam rooms, so every day we schedule three providers to treat in-office patients, one provider to conduct e-visits from home, and the other to be at the hospital so our overhead per provider is very low," he says. "Being able to provide 24/7 care is the centerpiece of a Patient-Centered Medical Home." Both Preslar and Dappen require all patients to come in for a face-to-face office visit before they can utilize remote services.

Understand payment

Reimbursement for telehealth services varies by payer and by state. Some states, including Texas, allow for only the reimbursement of live video consults; while others, including California, also pay physicians for the time they spend reviewing store-and-forward patient data. For its part, Medicare reimbursement is available for only a limited number of Medicare Part B services, namely live video services, which must be delivered in real-time via a telecommunications system that substitutes for an in-person encounter, according to the National Telehealth Policy Resource Center (NTPRC). Store-and-forward consults are generally not compensated, and Medicare does not reimburse for remote patient monitoring services, though legislation is in a constant state of flux.

Practices that are moving toward telehealth services and also accept insurance should check first with their payers to determine what is covered so they don't provide services that negatively affect revenue.

Identify state licensing requirements

In most cases, physicians are limited to practicing in the state or states in which they are licensed. That creates a quandary for technology-enabled healthcare, in which cross-country consultations are becoming more common. State policies governing telehealth and physician licensure vary widely, according to HealthIT.gov. Some allow cross-border delivery of healthcare via telehealth and others ban it outright. Physicians considering a telehealth program must check with their state licensing board to ensure they are in compliance. NTPRC summarizes state laws and reimbursement policies on its website (http://telehealthpolicy.us/), along with a list of pending laws by state.

Credentialing and privileging by healthcare organizations can also get muddy where telehealth is concerned. In 2011, CMS ruled that hospitals were permitted to use a new process to credential and privilege telehealth providers. But that rule, in some cases, conflicts with state policies. Thus, the NTPRC recommends providers check with their state Medicaid office on its telehealth credentialing policies. "My best advice is to get a lawyer who is knowledgeable about interstate telehealth and liability issues," says Gary Capistrant, senior director of public policy for the American Telemedicine Association. "There are all kinds of issues that come into play in an increasingly mobile society. There may be a primary-care doctor who wants back up from a specialist and often times those consultations trigger the need for a license."

Monitor effectiveness

Lastly, your telehealth program should include a mechanism to evaluate the impact of the service provided, and demonstrate its clinical effectiveness and financial effects. Set goals before the go-live date such as increased referrals, cost reductions, higher patient satisfaction scores, or improved patient outcomes, the Telehealth Resource Centers suggests. Compare data points and survey results with baseline measurements periodically to highlight opportunities for performance improvement.

Though still in its infancy, telehealth could just cure that which ails the U.S. healthcare system - rising costs and lack of access to care. It may also benefit private practices that have struggled with declining reimbursement. "Ten years ago, telemedicine revolved around large medical centers using very expensive equipment to essentially connect providers to providers," says Peter Antall, a practicing pediatrician and medical director of Online Care Group in Boston, a physician-owned primary-care network that offers telehealth services through American Well. "Nowadays, due to technological improvements, we're able to connect using standard equipment like home computers and cell phones to have meaningful encounters with patients." But significant pitfalls exist for physicians that rush in without appropriate planning.  As private practices deploy digital health solutions, they must be vigilant in the protection of patient privacy, ensure compliance with state licensing requirements, and continue to measure such services against a cost/benefit and patient outcome yardstick.

In Summary

Ready to start offering telehealth services? Here's what our experts say you need to do first:

• Conduct a needs assessment to determine patient demand

• Determine what, if any, additional technology you need

• Take steps to protect patient privacy

• Ensure you have adequate staffing

• Check with payers to determine what services to provide

• Understand state licensure requirements

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 20 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the May 2014 issue of Physicians Practice.