How to bring telemedicine to your GI practice



– Is your practice ready for telemedicine – and should you dive in?

Once you and your practice managers work through regulatory, legal, and technical details, having a robust telemedicine practice can boost patient and clinician satisfaction – and the bottom line, said Theresa Lee, MD, a gastroenterologist in private practice in Lone Tree, Colorado, speaking at the 2019 AGA Partners in Value meeting.

Dr. Theresa Lee a gastroenterologist in private practice in Lone Tree, Colorado Kari Oakes/MDedge News

Dr. Theresa Lee

The general field of telehealth – in which images might be shared or patients might message their care team for medication refills – is a broad term, said Dr. Lee. She explained that telemedicine is narrowly defined for Medicare and Medicaid reimbursement purposes as “two-way, real-time interactive communication between the patient and the physician or practitioner at [a] distant site ... that includes, at a minimum, audio and video equipment.” This is the video visit that many people think of when they imagine telemedicine, she said.

There’s increasing acceptance of telehealth services, said Dr. Lee, with a recent online poll showing that two-thirds of those surveyed would be willing to use telehealth; this would translate to about 24 million Americans who would be potential telehealth patients. And a 2019 survey of internal medicine physicians showed that more than half are working in practices in which telehealth is used in some capacity. Both patients and clinicians can benefit in a telehealth relationship, said Dr. Lee. The lack of physical travel and the potential for access after normal clinic hours can be a real boon for patients; “So how does this help us? How does it improve practice and make our lives easier?” she asked. Telehealth services can lead to improved efficiency, patient satisfaction and retention, and the ability to stand out in a market, especially if a practice can initiate telehealth services now, during the rapid growth and adoption phase for this newer technology.

“You want to make sure you really understand what some of the legal issues are surrounding telehealth and telemedicine,” said Dr. Lee, to ensure compliance with state and federal laws. There can be barriers to practicing across state lines; some states require an initial in-person visit, or the signing of a consent form, before initiating telemedicine; others may limit controlled substance prescribing via telemedicine.

And the mode of communication matters, said Dr. Lee: “Why can’t we just use Facetime to call our patients? The first thing to think about is privacy, and unauthorized access to data,” so it’s critical to do your research and use fully HIPAA-compliant communications technology.

Technology – and pricing plans – can vary widely, she added. “There’s some benefit to including technology that integrates with other clinical programs;” the platform Dr. Lee’s group chose communicates with their EHR for such functions as scheduling.

Pricing models can vary; a common scheme charges a per-user monthly fee, though blanket-fee plans also exist. Some telemedicine platforms use a hybrid pricing model that charges a flat fee up to a certain number of users and then adds a per-user fee after that.

Best practices to manage liability include continuing to maintain high standards of compliance after attorney consultation and notifying your practice’s malpractice insurance carrier, said Dr. Lee.

Reimbursement is on the upswing, as insurers see the benefits of telemedicine, and employers see their patients needing less time off work for appointments, and there are fewer emergency department visits for after-hours problems. Medicaid reimbursement is fairly straightforward, but Medicare is more restrictive and requires the beneficiary to be in a rural originating site.

Coding for a telemedicine visit is strictly based on face-to-face time spent in video conference, said Dr. Lee, at levels on par with time-based coding for office visits. “But you’re not including that time you spend doing chart review and not including the time you spend coordinating care.”

Dr. Lee’s own experience with telemedicine began in late 2016, when the 22-physician general gastroenterology group looked into it as a way to increase growth.

During the first half of the next year, the gastroenterology group’s administrative leaders and an engaged physician proponent vetted a number of telemedicine companies, and the group tried the leading candidates’ technologies.

By mid-2017, the comprehensive gastroenterology group, which also employs six advanced-practice clinicians, was piloting video visits with a group of four physicians. “One of those physicians was actually one of my partners who had sustained an Achilles tendon injury, so wasn’t really coming to the office post surgery. He was starting to use this at home, to do video visits, and everything went pretty smoothly with that,” said Dr. Lee.

When this trial was successful, the group went all in, with on-boarding of clinicians accomplished by the end of the year, site visits and 1:1 training provided by the telemedicine platform providers.

The practice is seeing video visits continue to grow in popularity, among both patients and clinicians, said Dr. Lee. She shared some tips and lessons learned from her practice.

There’s currently no formal protocol that selects patients for participation in the telemedicine program at Dr. Lee’s clinic. Providers may offer video visits to patients, and triage nurses also can suggest that patients ask their provider about them; flyers in waiting rooms and exam rooms encourage patients to ask about the possibility.

The practice maintains a telehealth committee that includes the practice’s president and administrator, about three core physicians who are strong telehealth champions, and additional physicians who are high telehealth users. The committee also folds in the office and information technology managers to make sure issues of workflow, billing, and technology are addressed.

Some practical considerations can pose challenges to a successful telemedicine program, said Dr. Lee. Connectivity problems on the patient end are fairly frequent, and no-shows also can be a problem. On the clinic side, not all clinicians have embraced video visits. For these low users, telemedicine may not represent a good value proposition. However, she said, they are seeing more and more clinicians come on board with video visits as word gets out of the generally positive experiences others are having.

Dr. Lee suggested several ways to up telemedicine utilization and make it work within your practice. “Identify which patient would benefit most,” she said – this might be patients with inflammatory bowel disease who mostly need medication management, or patients with limited mobility or who live far away. Staff can also help a patient get a same-day visit by scheduling a video visit with an available clinician. By mentioning video visits as an option for uncomplicated issues or a way to get a rapid read on a new concern, clinicians can get patients thinking about telemedicine as an appealing option.

In some clinics, exam room space can limit clinician productivity, and scheduling a block of video visits when space is tight can be a great solution. Clinicians can optimize their schedules if they incorporate video visits, said Dr. Lee, citing the example of a physician assistant in her practice who stacks video visits in the evening hours, so she’s able to be with her preschool-aged children during the day. After-hours video visits have been popular among patients too, said Dr. Lee, so the scheduling flexibility may help with both patient and provider retention, and be a practice differentiator.

“There’s great potential for value through improved patient satisfaction, provider efficiency, improved health care outcomes, and cost efficiency,” she said.

Dr. Lee reported that she had no relevant disclosures.

AGA has partnered with SupportedPatientTM, a HIPAA-secure telemedicine platform. It allows you to expand your practice and connect your patients with additional specialists. Learn more at https://www.gastro.org/practice-guidance/practice-updates/supportedpatient .

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