Getting started with Telemedicine in New York
COVID-19 arrived and has wreaked havoc with our medical practices. Patients need chronic care and follow up. Patients need to be advised in real time about situations that may be urgent. Our offices have been shuttered, but technology has allowed us to be present and available – virtually. We have a personal account of a physician navigating the telemedicine mind field – he will tell you all the do’s and don’ts, the ins and outs, and the hates and loves. Following the personal account, will be the technical aspect of signing up for telemedicine in the COVID-19 era. There are lots of live links that will expand on detail and get you to a promising end result . So, hang in there, get comfortable, and read on for an in-depth look at Telemedicine in New York!
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Due to the COVID19 pandemic, several adjustments are necessary to ensure patient access to care. With physical distancing as the key limitation to conventional face-to-face care, telemedicine offers a timely alternative. Although the practice of telemedicine is not new in the USA, its utilization varies by state, payers, and specialties. Centers for Medicare and Medicaid Services (CMS) and several state governments have swiftly enacted regulations to facilitate the practice more broadly.
The delivery of healthcare services can take several forms, such as: private practitioners of all sizes (solo, small and medium-size groups); employed healthcare providers of major health systems and academic centers, both public and private. This variance is reflected in the way challenges and opportunities are approached by these practice forms. Generally, large health system are equipped with amazing technologies and versatile EHR (electronic health records), therefore better prepared for a speedy adoption of telemedicine. More broadly, community healthcare providers in private practice are slow to embrace this new normal due to several barriers including, but not limited to knowledge gap, technology, infrastructure, concerns about reimbursements, liability coverage, and other patient population-level barriers.
Essentials for Incorporating Telehealth
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My current account is informed by firsthand personal experience in a large academic center, Montefiore Medical Center, as an OBGYN academic specialist.
Below, I present a summary outlining the basic set-up required for telehealth visit.
Patient Provider
HARDWARE
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(audio/video) cell phone, tablet, computer Printer Headset, headphones, webcam cell phone, tablet, computer headset, headphones, and webcam
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SOFTWARE
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EHR portal with email messaging, mobile applications, Facetime, WhatsApp EHR with telehealth options, mobile applications Facetime, WhatsApp Doximity account
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TELECOM
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Cell phone with data plan, robust internet connection
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SPACE
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Home or patient choice. home office, quiet, private hospital call room, clinics, etc.
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TIME
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Morning, Afternoon, Evening of Weekdays and Weekends
The Telehealth Visit
Intake
Staff calls the patient the day/night before the visit to educate about the process of telehealth and notify the patients of non-identified phone calls from providers, discuss consents, and answer potential questions. Blood pressure measuring device, thermometer can be purchased by the patient at local pharmacies or may be ordered by provider.
The morning of the visit, the patient list is uploaded by staff and arrived based on the scheduling roster. If after two or three attempts with no answer, patient may be considered “No Show”, depending on practice policy.
Encounter
Either via audio or video, a call is made to the patient with appropriate greetings and introduction. First, a verbal consent is obtained and documented. The start time is recorded from the timer. The encounter continues similar to a conventional patient visit with chief complaint, history of present illness (HPI), etc. Vital signs adequately taken by the patient need to be recorded. If using video, limited inspection of the body can be performed and documented.
The medical decision making is documented through the assessment and plan sections (combined or separated), including differential diagnosis, orders, referrals, transfer to ED or direct admission.
Exit
Orders, follow up visits, education materials are sent via email through the EHR to both patient and staff as deemed appropriate. Prescriptions, injections (immunization, contraception, etc.) are sent to pharmacy on record for pickup and administration.
Compensation
The telehealth visit is charged through the EHR by time not by level.
Physicians: CPT: 99441: 5-10 minutes, 99442: 11-20 minutes, 99443: 21-30 minutes
Other
Issues: communication charges, identification/privacy, return calls, etc.)
Solutions: Software applications (Doximity, other)
Common Issues
Patient has no technology (no device, no internet or both)
Language barriers, how to use translation services? Challenges with telehealth video.
Patient has device, does not know how to use in the context of telehealth.​
Staff failed to alert patient.
Patient does not answer. No show?​
Patient declined telehealth. What's next?
More than one patient in the household, how to proceed?​
Definitions
telemedicine
typically refers to the practice of medicine using technology to deliver care at a distance. A physician/clinician in one location uses a telecommunications infrastructure to deliver care to a patient at a distant site. Telemedicine is a subset of telehealth.
telehealth
refers to a broader scope of remote health care services than telemedicine. Telemedicine refers specifically to remote clinical services between a provider and a patient/client, while telehealth also refers to remote non-clinical services (for example, clinician to clinician consults, patient education services, interprofessional care team communications, etc.).
remote patient monitoring
(RPM)
refers to using technology to gather patient data outside of traditional healthcare settings: for example, using digital scales, glucometers, pulse ox devices, etc.…to monitor a patient’s condition while they are at home (or wherever else they may be living). It too is a subset of telehealth.
mhealth
mHealth is an abbreviation for mobile health. It simply refers to the subset of telehealth that use mobile technologies. Examples include apps and peripheral devices designed for use on smart phones and tablets for videoconferencing or gathering patient data or providing patient education or secure communications.
LEGILSLATION - CARES ACT & TELEMEDECINE
Congress did much to speed acceptance of telehealth as part of the $2 trillion stimulus package. The CARES Act awards $200 million through the Federal Communications Commission to medical groups to help them install the technology and fund broadband installations. The groups also can apply for $27 billion in a public health emergency fund. Please see the document below.
Funding Opportunity from the FCC
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The FCC launched a new telehealth program using $200 million in federal funding to improve connected health services because of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The program offers qualified healthcare providers the means to provide connected care services to patients by fully funding their telecommunications services, information services, and devices. Funding is provided on a first-come-first-serve basis and will be available until funds have been expended or the pandemic has ended.
Guidance on the application process for FCC funding can be found here:
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Guidance released on April 8th, 2020.
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Eligibility Determination:
Healthcare providers interested in participating must obtain an eligibility determination from the Universal Service Administration Company (USAC) for each healthcare provider site included in their applications. Eligibility determination can be obtained by filing FCC Form 460 with USAC.
The FCC Form 460 can be found here:
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Applications can be filed through a dedicated application portal, which will be available beginning Monday April 13, 2020 at 12:00 PM ET on the COVID-19 Telehealth Program page here:
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What is happening in
New York State ?
PAY KEEN ATTENTION TO THE SECTION BELOW!
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Northeast Telehealth Resource Center
Serving: New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), New York, and New Jersey)
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THE LINK BELOW IS THE STEP BY STEP GUIDE FOR NE YORK STATE – PLEASE CLICK ON THE LINK
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What type of Teleservices are reimbursed?
Practical Steps
– Set up a team that will help facilitate the expedited implementation of telemedicine services and be able to make decisions quickly to ensure launch as soon as possible.
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Check with your malpractice insurance carrier to ensure your policy covers providing care via telemedicine.
– Familiarize yourself with payment and policy guidelines specific to various telemedicine services
1. GETTING STARTED IN THE CLINICAL WORLD
2. VENDOR EVALUATION, SELECTION, CONTRACTING
– Set up a team that will help facilitate the expedited implementation of telemedicine services and be able to make decisions quickly to ensure launch as soon as possible.
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Check with your malpractice insurance carrier to ensure your policy covers providing care via telemedicine.
– Familiarize yourself with payment and policy guidelines specific to various telemedicine services
During the COVID-19 emergency, physicians and practices can leverage technologies such as FaceTime, Skype, Zoom, etc. This will help speed up the implementation process. OCR guidance emphasized that physicians are encouraged, but not required, to notify patients of the potential security risks of using these services and to seek additional privacy protections by entering into Business Associate Agreements (BAAs) as able.
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Make sure you understand who has access to and owns any data generated during a patient visit
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Get clear on the pricing structure (i.e. is there a monthly flat rate for using the technology or is it per call or per visit?)
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Recognizing that many physicians and care teams are working remote, the AMA and American Hospital Association created guidance to help you ensure your personal and home devices are secure.
* Given the special circumstances of the COVID-19 pandemic, the federal government has announced that the Office for Civil Rights (OCR) will exercise its enforcement discretion and will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) in connection with the good faith provision of telehealth during the COVID-19 national public health emergency.
3. ENSURE HIPAA COMPLIANCE
Workflow & Patient Care
Protocols
Determine protocols for if/when a telehealth visit is appropriate up front and train clinicians, care team members and schedulers. Consider a short survey or set of questions that patients can either answer electronically or over the phone when your patients are scheduling to properly triage.
If you know your payer mix, consider reaching out to the payer with the highest percent of your patient population to discuss telehealth coverage, even if temporarily due to current events.
Schedule
Determine when telehealth visits will be available on the schedule (i.e. throughout the day intermixed with in-person visits or for a set block of time specifically devoted to virtual visits).
Space
Set up space in your practice to accommodate telehealth visits. This can be an exam room or other quiet office space to have clear communication with patients. If multiple members of the care team will be helping to facilitate telehealth visits, ensure they know where to support the set-up of the technology and communicate with patients virtually.
Records
Ensure you are still properly documenting these visits – preferably in your existing EHR as you normally would with an in-person visit. This will keep the patient’s medical record together, allow for consistent procedures for ordering testing, medications, etc. and support billing for telehealth visits.
Consent
Ensure you receive advanced consent from patients for telemedicine interactions. This should be documented in the patient’s record. Check to see if your technology vendor can support this electronically.
Awareness
Let your patients know the practice is now offering telehealth services when they call the office. Have your office staff help support pro-active patient outreach. Additionally, post announcements on your website, patient portals and other patient-facing communications.
Access
Have a plan for supporting patients on how to access telehealth visits based on your practice’s technology and workflow to keep the clinic flow moving and avoid disruptions to care.
Workflow Tools & Resources
Telehealth workflow best practice (PDF), ensuring your workflow addresses the entire life cycle
Telehealth etiquette checklist (PDF), tips on conducting a successful telehealth visit
Key considerations when designing a telehealth workflow (PDF), key questions and criteria for designing a workflow
Patient take-home prep sheet (PDF), patient education on telehealth, how it works and how to prepare/what to expect from your appointment
Telehealth workflow example (PDF), sample flow for scheduling, check-in, visit, and post-visit
CMS - Medical Learning Network - Telehealth Services
TeleHealth during Public Health Emergency Table
TeleHealth Billing Flowchart by Service Rendered