Telemedicine

What is telemedicine?

Coined in the 1970s, the term telemedicine means “healing at a distance.” Telemedicine is the remote real-time delivery of healthcare via technology. Every day, more healthcare providers are leveraging evidence-based telecommunications and information technologies to care for patients in homes, offices, and even backyards or vehicles. Telemedicine is gradually improving the access to and the quality of health care across geographic and socioeconomic lines.

A brief history of telemedicine

Medical care needs on long-duration space missions prompted NASA and Nebraska Psychology Institute engineers to develop telemedicine technology in the late 1960s, according to a paper published in the International Journal of Environmental Research and Public Health. Their remote monitoring project on an Arizona Indian Reservation lasted until 1977, spotlighting equipment malfunction and video consult time challenges.

Although the history of telemedicine is long, its adoption has been slow due to technological, financial, legal, strategic, and human resource barriers. In 2010, President Obama proposed “Connecting America: The National Broadband Plan” to support the implementation of broadband networks across the U.S. with medical network build-outs that facilitate telemedicine. Expanding dedicated health bandwidth across more health networks (mobile and land-based) will facilitate cost-effective video consults, remote patient monitoring, and connected-care solutions.

Though the lack of broadband infrastructure has impeded the advancement of high-demand video and store-and-forward services, the COVID-19 pandemic has precipitated healthcare reforms and federal legislation, promoting technological advancements like EHR systems, electronic prescribing, and mobile health apps.

What is the difference between telemedicine and telehealth?

Telemedicine refers specifically to remote clinical services, while telehealth refers to a broader scope of remote non-clinical services like healthcare provider training, administrative transactions, and continuing medical education.

While telemedicine is a term that’s traditionally been used to describe the delivery of care by physicians, telehealth encompasses services provided by a wide spectrum of health professionals including nurses, physician assistants, pharmacists, therapists, psychologists, licensed clinical social workers, complementary and alternative healthcare professionals, as well as public health providers.

Telemedicine pros and cons

Like every new treatment and every new technological innovation, telemedicine features advantages and disadvantages — depending on who is using it, where, and for what purpose.

For patients, the advantages of telemedicine include:

Lower costs: besides saving on commuting and childcare costs, Medical News Today cites studies demonstrating that telemedicine users require fewer hospitalizations.
Expanded care access: telemedicine makes it easier for patients with disabilities, patients over the age of 65, patients who are geographically isolated, and those who are incarcerated to get healthcare.
Preventative care: multiple studies have found that preventive telemedicine improved health outcomes — especially for patients with financial or geographic barriers.
Convenience: telemedicine allows patients to enjoy care from any location where they find comfort and privacy — without taking time off of work or paying for childcare.
Slowing infection spread: telemedicine eliminates the risk of catching an infection in a crowded waiting room — especially for immunocompromised patients.

However, telemedicine is obviously not a good fit for all patients who need emergency care — a healthcare professional cannot provide life-saving care or laboratory tests digitally. According to the National Telehealth Policy Resource Center, only 26 states currently require insurers to cover or reimburse the costs of telemedicine. Many patients are also concerned about protecting their health information from hackers and other criminals, especially when accessing telemedicine via a public network or unencrypted channel.

For healthcare providers, the advantages of telemedicine include:

Lower overhead: healthcare professionals who pay less for front desk support and get by with fewer exam rooms in a doctor’s office may be able to charge less for services.
Increased revenue: telemedicine allows healthcare providers to deliver more hours of care to more patients.
Minimized infection exposure: when providers see patients remotely, they don’t have to worry about exposure to any pathogens the patient may carry.
Increased patient satisfaction: a patient who doesn’t have to spend hours traveling to and waiting in the doctor’s office is likely to be more satisfied with real-time telehealth.

The most obvious telemedicine drawback is the inability to examine patients. Video visits require clinicians to ask more health history and symptom questions, but there are many symptoms that must be seen, touched, and instinctively diagnosed — which means some telemedicine sessions can compromise treatment.

Licensing issues also stifle the implementation of telemedicine. State laws vary — healthcare professionals may not be able to practice across state lines if they hold a license in a state other than the one where the patient lives. Many healthcare providers also have technological challenges because they can’t find or afford the right digital platform or a strong enough connection. Ensuring that a telemedicine program is secure and fully compliant with privacy laws also requires investing in some telecommunications technology education.

How to deliver telemedicine

The idea of implementing telehealth services may seem daunting at first, but if you follow proven steps provided by medical education sources like Medscape, you’ll soon be a thriving telemedicine provider:

Inform and ask your patients. Are your patients aware that you offer telemedicine? When they see signage in their doctor’s office or articles on their healthcare provider’s website, do they absorb the news? It may also help to have office staff explain the advantages and workings of telemedicine during regular visits. Ask your patients if they are open to video visits if it means shorter wait and transit times. Determine which services they’d be interested in by asking or offering them a questionnaire to fill out.
Create a plan. Decide what you want to accomplish with telemedicine. Do you want to become more accessible for in-person visits, or will you use telemedicine for after-hour care? Are you looking to add more Millennial patients, who are more comfortable with the technology, to your practice? What services are most important to them?
Choose a form of telemedicine. Payers are more likely to cover audio-video services, but asynchronous telemedicine is more effective for dermatology, pediatrics, or as an adjunct to audiovisual visits. Asynchronous platforms are more conducive to healthcare providers’ schedules, allowing them to process messages on their own time.
Recruit your care team. Your staff may identify any logistical problems, like implementing video and in-person visits and scheduling — sharing decision-making is a great way to gain support for your telehealth transition.
Learn about coverage and regulations. Learn what telemedicine services your payers reimburse. Medicare and some Medicaid programs require patients to come into a facility. State regulations may limit telemedicine forms, patient locations, and patient status or informed consent.
Decide how to use telemedicine. Will you offer same-day telehealth appointments, after-hours care, or immediate video visits? At the end of certain in-person visits, you may recommend telemedicine for follow-ups.
Start with just a few services. Limit yourself to simple real-time video visits for services like medication refills, blood pressure reading, diabetes check-ins, and preoperative or postoperative visits.
Choose a telemedicine platform and simple technology. Choose a platform that’s easy to sign up for — a patient portal is best. Consult with other healthcare providers who offer telemedicine and get recommendations. The simplest setup for video visits is a computer with a camera that links up to your software. Invest in a headset with a microphone, which plugs into your computer for crisp audio. Study privacy regulations of every platform and technology.
Integrate with scheduling. Post your telemedicine visits on your practice’s schedule. Telemedicine software through electronic health record (EHR) systems often integrates into your schedule. Standalone software may require manual entries.
Set up your space and do a trial run. In a quiet, private, well-lit room, set up your technology and practice a telemedicine visit with staff who can offer valuable feedback. It’s a great way to resolve technical problems and develop an engaging demeanor.

What services can be provided via telemedicine?

The evolution of telemedicine has expanded the use of technology into these settings:

Home and community-based care

According to the NCBI, chronic disease has created the biggest need for in-home and community-based care. The 100 million Americans with chronic disease account for about 75% of U.S. care costs. Telehealth technology is conducive to Care Management, which requires frequent contact and regular biometric reporting, personalized education, monitoring, and feedback at home from a remote support team. Care Management for chronic disease has enabled reductions in hospitalizations, readmissions, lengths of stay, and costs. It has also improved medication compliance, patient satisfaction, and health outcomes.

Office-based

Store and forward (S&F) telehealth in ophthalmology and optometry has streamlined care and increased screening rates with non-mydriatic cameras that perform retinal screenings on patients managing diabetes without dilating the eyes. Teledentistry has improved access to oral health care, dermatology, and psychology. Studies have shown that the same diagnosis and treatment plans result from in-person visits and those developed using telehealth technologies — and satisfaction rates are high in all three specialties. Healthcare professionals are benefitting from more integration of telemedicine and decision support systems into electronic health records.

Ancillary services

Telemedicine is enabling and improving these ancillary services:

Teleradiology: Instead of passing film through a digitizer, systems now use direct digital capture, which allows providers to read images overnight across the globe. Radiologists rely on the Digital Imaging and Communications in Medicine (DICOM) standard for transmitting and storing data. Teleradiology has reduced the need for transports for head injuries out of rural areas and that video visits significantly improved diagnosis and treatments.
Telepathology: digitization of pathology slides in large files require the ability to view color images under various magnifications which are hard to move across firewalls — new models allow the image to sit on a server and be viewed from afar without needing to be moved. NCBI published studies that demonstrated 74% of case diagnoses were more precise via telemedicine than on-site.
Telepharmacology: facilitated by computerized order entry, remote review, and even remote dispensing combined with video visits, telepharmacology allows the whole pharmacy visit to occur remotely. The NCBI found that 47 rural cancer patients saved 27,000 miles of travel and 19% caught one or more medication errors via pharmacist technology.

Hospital-based

Hospital-based telemedicine is growing dramatically in stroke care and intensive care (ICU). High-quality stroke imaging can be done remotely, reducing lengths of stay, mortality, and costs. Telemedicine reduces ER visits for skilled nursing patients — especially in rural facilities that don’t have physicians. Nursing homes across the country are embracing telepsychiatry for geropsychiatric care with positive results. Telesurgery has also been used on a small scale and is being tailored to various settings.

Telemedicine clinical guidelines

To effectively leverage and expand telehealth, digital health, and virtual care technologies, federal and state health policy must be technology-, modality-, and site-neutral.

The American Telemedicine Association (ATA) has established these policy principles:

Ensure patient choice, access, and satisfaction.
Promote provider autonomy.
Expand reimbursement to incentivize telemedicine.
Enable healthcare delivery across state lines.
Promote access to non-physician providers.
Expand access for underserved and at-risk populations.
Support “aging in place” solutions.
Protect patient privacy.
Monitor your program integrity.

The ATA has also released three new guidelines for the practice of telemedicine and invited the public to comment on them as they pertain to the treatment of stroke, pediatric and adolescent mental health care. As the organization collects and analyzes feedback, standards will reveal themselves.

Telemedicine and Medicare/Medicaid

Patients who have coverage through Original Medicare or a Medicare Advantage Plan do not have to pay out-of-pocket for COVID-19 tests.

Medicare also offers these telehealth services:

Renal dialysis at home
Emergency department visits at home
Physical and occupational therapy services at home
Services delivered via audio-only devices
Video visits

The COVID-19 pandemic has also temporarily expanded the list of telehealth services payable by Medicare to include:

Psychological therapy
Dialysis
Eye exams
Speech and hearing therapy
Oral function therapy
Cochlear implant
Speech device service
Tinnitus assessment
Cardiac rehabilitation and monitoring
Aphasia assessment
Neuromuscular and gain-training therapy
Adaptive behavior therapy
Wheelchair and assistive technology training
Prosthetic training
Medical nutrition therapy
Caregiver assessment

Telemedicine: what’s next?

During the COVID-19 pandemic, providers received the exact same reimbursement for telehealth from the Centers for Medicare and Medicaid Services (CMS) as they would for an in-person visit. That’s not likely to continue, but it’s not clear what payers will decide to cover in the future.

Because telehealth is considered a less intense form of care, reimbursement for certain services may be reduced. Healthcare providers may provide only practice certain services virtually if it takes them more time to perform a telehealth consultation and they get paid less for it.

The BDO Center for Healthcare Excellence and Innovation recommends focusing on these improvements:

Enhance EMRs and EHRs: When healthcare providers conduct virtual care, the patient-provider dynamic changes — the EMR needs to be referenced more quickly. Technology that allows access to necessary screens is needed to streamline workflows and reduce the time needed to navigate EMRs or Care Management platforms.
Balance virtual with in-person visits: As patients begin returning for in-person visits, new workflow issues will make social distancing a challenge. Patient turnover will take longer due to the need to sanitize rooms between visits. Healthcare designers may design their workflow to alternate between virtual and in-person visits — the optimal mix is still being determined.
Collaborate with other providers: With most current virtual visits, the entire episode of care occurs with a single provider — there must be a way to pass patients between various team members (medical assistants, nurses, specialists, and schedulers). Technology must evolve to enable multidisciplinary team-based care, bringing specialists and complementary providers into the telehealth visit. Consumer-facing solutions like Zoom® offer the infrastructure, but security and reimbursement must be addressed for telehealth to flourish.
Pass legislation that incentivizes adoption: Telehealth involves new procedures for providers and patients which can lead to connectivity issues. Healthcare providers may find themselves spending part of their visit helping patients troubleshoot tech issues, decreasing the efficiency that telehealth is supposed to provide.

To learn more about how you can leverage technology to deliver a wider spectrum of care for a greater number of patients, read our robust article about telehealth here.