Developing telehealth services for a clinic or independent practice to handle patient assessments and questions during the COVID-19 outbreak should start with an assessment of:
- Viability of serving patients remotely based on the type of specialty the practice offers
- HIPAA and other legal considerations when offering remote services
- Whether insurance can be billed for service delivered remotely
- Whether the organization has the resources available to build a telemedicine program, including:
If that assessment determines that offering telehealth services is feasible and affordable, the best practices for getting started are:
- Acquiring hardware and software to deliver remote services
- Training staff and lining up technical support resources
- Identifying patients and types of service that are viable candidates for telemedical visits
- Laying the groundwork with patients to begin remote services
- Designing systems and processes for managing remote appointments and follow-ups
Telehealth Services Offer Fast, Convenient, Safe Visits During the Pandemic
While intensive care units and emergency departments have been overwhelmed with patients, many health care facilities have gone quiet during the pandemic for various reasons:
- Stay-at-home orders eliminate elective procedure visits
- Patients and providers both have cancelled non-emergency visits for fear of cross-infection
- Medical staff have been laid off due to dramatic reductions in revenue
Telehealth has been on the cusp of becoming mainstream for almost a decade. Even outside a pandemic environment, it has a number of advantages for both patients and providers:
- Easy access to healthcare professionals, particularly for patients with mobility issues
- Less lead time for appointments
- Quicker turnaround for providers between appointments
- No facility limitations
When a highly dangerous, infectious disease like COVID-19 is in the wild, the advantages are all magnified by the inherent safety of remote consultation. The onset of the pandemic has been so fast that it has not allowed providers or patients time to prepare for telehealth, however.
There are a number of steps you’ll need to evaluate to see if telehealth is an option for your practice.
Can You Legally Offer Telehealth Services?
For starters, you’ll have to check your state regulations on telehealth visits. These will determine if you are even allowed to offer services remotely, and have some impact on which services and how you will be allowed to bill for them.
In the current crisis, most states have started to relax prior restrictions on telehealth services, but no general guidelines exist. You’ll have to check your state rules specifically. The Alliance for Connected Care is maintaining a COVID-19 resource page that includes summaries and links to state rules that have been altered for the pandemic.
One big hurdle was cleared in mid-March, as the Centers for Medicare and Medicaid Services (CMS) declared that they would pay providers for telehealth care for beneficiaries in any region, not just rural areas as was previously the case. That includes advanced practice registered nurses.
In some cases (as with Medicare), the way in which you deliver services will matter for billing or authorization—CMS requires that the visit include real-time audio and video interaction to be covered. That can really limit availability; even if your office has the technology for such visits, many patients may not, or may not have the capacity to figure out how to use what they have.
On that point, however, CMS has also waived HIPAA security rules around the videoconferencing solutions, so you may have more options to choose from rather than forcing patients into something they aren’t familiar with.
Is Your Practice Area Practical For Telehealth?
You’ll need to determine if your area of specialization is something where services can be practically offered via telemedicine. Of course, every specialty has certain services or procedures that have to be delivered in person… not many babies are going to be born via telepresence, for instance. For that matter, neonatal nurse practitioners can’t accomplish much without the direct presence of their patients and the highly specialized equipment needed to work with them.
But nurse midwives don’t have to get too hands-on for the first eight-odd months with their clients. Consultations and advice can easily be practiced online. Neonatal NPs, by contrast, don’t really have much practical use for telehealth.
The boundaries may be further off than seems apparent, though. Depending on your organization and the investment it is prepared to make, partial telehealth systems could be practical. Tele-ICUs have been operating since the early 2000s with some success, integrating hands-on care from limited numbers of on-site providers with expert monitoring and consultation via telehealth.
You’ll have to assess your specialization and practice area to determine if it’s feasible to offer some or most of your services via telemedicine, and decide if the investment will be worthwhile with that in view.
Do You Have the Budget and Resources For a Telemedicine Program?
Although telemedicine doesn’t have to be an expensive proposition, particularly with some of the constraints lifted thanks to emergency practice exceptions put in place during the COVID-19 outbreak, it’s not going to be free. You’ll have to devote funding to areas like:
- Hardware and software acquisition
- Technical support
While it seems likely that telemedicine is going to be a long-term investment, it’s also true that no one knows exactly how long the current state of affairs will last. So you will need to weigh resource commitments against what you think the lifespan of the project will be. Some areas are already lifting stay-at-home orders for elective medical procedures. Whether or not patients will continue to feel comfortable coming in is something you’ll have to determine for your own practice.
Putting Together a Telehealth Program
Whether you are doing so as an independent provider or as a task force lead in your organization getting a telemedicine program started, there are several key steps to take before announcing or rolling out services.
Conduct a Technology and Resource Assessment
Your first step will be to establish whether or not you have the technical skills and capabilities to offer remote services.
People – Do you have staff with the right skillsets to operate telehealth systems? This encompasses a number of skillsets:
- Basic technical skills
- Comfortable interacting with patients remotely
- Ability to successfully assess and interview patients remotely
Equipment – Does the practice have, or can it acquire, the necessary computer or phone hardware to offer telemedical services? This very much depends on the service; most ad hoc programs being put into place won’t count on much more than a basic laptop and webcam, or portable tablet device, at most. On the other hand, more extensive services can be offered, long-term, with an investment in or access to:
- Dedicated telehealth monitoring systems, like remote blood pressure and other monitors
- Telehealth kiosks, such as are found in some pharmacies, with built-in equipment and video connectivity
- Mobile medical devices, like networked ECG monitors or glucose trackers
Connection – Does the practice, or individual providers (if working from home), have fast enough and stable enough internet service to perform telemedicine consultations? Keep in mind the high demands of video-based systems, and the importance of a stable and high-quality connection with patients. The patient side of the equation is also important. You will have to take into account the overall internet availability and quality in the region where you serve patients.
Preparing Staff for Telehealth Service
Even if your staff have the basic technical skills and comfort with performing remote services, they will almost certainly need some additional training that is specific to your selected system and procedures. This can include:
- Learning the nuts and bolts of operating the video conferencing or other programs used for patient communication and/or monitoring
- Basic troubleshooting steps for when things go wrong mid-visit
- Escalation steps for getting rapid technical assistance
- Clear guidance for allowable medical activities that can be performed in a telemedicine visit
- Documentation and billing procedures
Rather than putting together a complete training program together in-house, consider using an outside resource for training. The California Telehealth Resource Center, for instance, offers no-cost training online.
Preparing Patients for Telehealth Services
Patients will also need some preparation to accept telepath services, both as a technical matter and in terms of trust and efficiency. It’s best to start with a brief letter or email advising that telehealth services will be available, and outlining topics such as:
- What types of visits can be accommodated
- When to schedule an in-person appointment instead
- The minimum system requirements to connect
- How telehealth visits will proceed; what they should do to prepare, what questions may be asked, how to interact with the provider
A new workflow might be required for telehealth visits. If possible, it’s a good idea to pre-test the connections with patients, a step that can be handled by medical assistants or other office staff before the provider is involved. They’ll need to make sure that both ends of the connection can see and hear clearly, and be familiar with basic troubleshooting steps to help get patients up and running.
Start each visit with a contingency plan for what should happen if you get disconnected, so patients are left in the lurch if the technology fails.
Be prepared to refer patients to designated technical support resources, either in-house or with trusted third parties… nothing is more frustrating than not being able to tell a patient where to turn to resolve a problem.
As an ethical matter, you’ll need to get consent from your patients to serve them via telehealth systems. Consent forms are available from the American Telemedicine Association in your organization doesn’t already have its own.
Understanding The Limitations of Telehealth Services
Telehealth can be a great tool for increasing access and speeding up some healthcare services, especially in a crisis where mobility may be limited. But it’s not a panacea. APRNs should be familiar with the limitations of telehealth visits in order to set expectations and assess when to recommend an in-person visit when the benefits could outweigh the risks.
Limited Physical Examination – Some of the most basic parts of the average office visit are maddeningly out of reach in most telemedicine setups. You’ll be unable to conduct any sort of essential physical examination.
Technical Problems – Even with the best systems and training, technical issues are inevitable. If you thought electronic medical record systems made you want to toss your iPad through a window, you haven’t seen anything yet.
Security Issues – The internet is a dangerous place, and with more and more vital information streaming across it right now, it’s more of a target for hackers than ever before. Added to that, many systems being used for telehealth today were never designed for the purpose, and the strain combined with the additional hacking activity could open your systems up to attack.
Regulatory and Industry barriers – Not all states or agencies have given a complete go-ahead for telemedicine in every practice area. Even when they have, insurers are struggling to catch up. You’ll run into considerable friction and maybe even outright roadblocks. Making matters worse, many of the exemptions that have been offered are temporary in nature; it may be frustrating to get your telemedicine program running like clockwork right before your state decides to yank the authority to use it.
Finding Assistance For Building Your Telehealth Program
Considering the long-term impacts of reduced healthcare availability, spinning up new telemedicine services has been a high priority for both healthcare organizations and public health officials.
You may be lucky enough not to be starting this process from scratch. A 2013 survey found that more than half of American hospitals were implementing telehealth programs, while another 10% were exploring such programs. And 64 percent of Americans reported in 2015 that they would be open to telehealth visits replacing some office visits. That already indicated a pretty open-minded patient population, and with COVID-19 raging, the number has undoubtedly gone up quite a lot.
If you are in independent practice, or in charge of telemedicine programs at your organization, there is federal assistance available to help fund new telehealth services. The FCC (Federal Communications Commission) is administering two different funds that represent a pool of $300 million to be distributed to providers getting telemedicine systems up and running.
AANP’s COVID-19 resource page has a dedicated telehealth section that has links to a number of resources, including specialty-specific guidance.
Your current IT resources should also be able to offer assistance on some of the nuts and bolts issues of getting your program up and running. You will also want to bring them in early on as a potential technical support resource for both providers and patients, who will inevitably run into difficulties with unfamiliar systems.