Tips on how to get started with telemedicine

The COVID-19 pandemic has had wide-ranging effects on the practice of medicine. These include cancellations of in-office visits, surgery postponements or cancellations, social distancing in the office, and the explosion of telemedicine. As a result of the pandemic, the federal government has instituted emergency measures that lift restrictions on the use of telemedicine. This Urology Times® webinar, featuring experts in telemedicine, practice management, and coding and reimbursement, examines the impact this public health emergency has had on the practice-related aspects of urology and how urologists can prepare for the future once the emergency declaration is lifted. (To view the webinar in its entirety, see bit.ly/uttelemedwebinar.)

The panelists were moderator Jonathan Rubenstein, MD, chief compliance officer, Chesapeake Urology Associates, Towson, MD and clinical associate professor, department of surgery, University of Maryland School of Medicine, Baltimore; John Gore, MD, MS, professor of urology, University of Washington, Seattle; Aaron Spitz, MD, a urologist in private practice at Orange County Urology Associates, Laguna Hills, CA and assistant clinical professor of urology at the University of California, Irvine; and Eugene Rhee, MD, regional coordinating chief of urology at Kaiser Permanente Southern California.

In this segment, the panelists offer tips for urologists who are interested in adding telemedicine in their practice.

Rubenstein: Let's talk about advice for somebody who doesn't have the same experience as our panel in doing telemedicine, is just starting out, is just getting on a platform, is just trying to bill. What are some words of advice, whether it's outpatient or inpatient, you would give to somebody who's new to telemedicine based upon your experience?

Gore: We're lucky in that being at the university, we were able to use institutional accounts like Zoom and had an easy platform for conducting our telemedicine visits. One of the things that we discussed is that even though the rules around HIPAA-specific platforms were relaxed, as Dr. Rhee and Dr. Spitz have noted, we are going to be entering this new domain where telemedicine is going to be a much more accepted, much better reimbursed mode of connection with our patients. I think taking the time to identify a HIPAA-specific platform now is really important because you want to start investing in a sustainable approach to telemedicine now, so that when we're post the COVID crisis, whenever that may be, you already have an established workflow and an established process for conducting telemedicine.

Also, I think it's very easy to turn over your practice to telemedicine when the entire practice is telemedicine. The other thing that we're trying to plan for is this post-COVID world where we're trying to balance our clinic deployments and our clinic workflows that mix telemedicine and in-person visits. We’re starting to do some thinking around how to navigate those workflows now.

Rubenstein: Dr. Spitz, what’s your advice for somebody who had to rush into this, based on all of your experience?

Spitz: Based on lessons learned, there are a few things I'd like to share as points of advice. First of all, it can be very scary to contend with a thought of, “Which disease states can I actually manage telemedically, which ones can I not manage telemedically, and where will I get in over my head?” I think trying to predetermine which kinds of patients you should attempt to engage telemedically is an unnecessary stress because telemedicine can be viewed not as an either/or, but as a “yes/and.” By that I mean you can literally engage any patient, no matter how acute they may appear to be based on their description, telemedically. If you determine through that telemedicine encounter that they need to be seen   on, then certainly bring them in, or direct them to the ER, or have them do whatever they would have already done for a hands on visit.

Seeing somebody telemedically does not in any way exclude your ability to see them hands on if that's what you determine needs to be done. But it may save that step for both you and the patient and there's no way to follow know until you engage them. Rather than getting too concerned with setting up algorithms of which patients you will or won't see, feel liberated to see all patients telemedically if you desire and then you can decide from there if additional visits are needed. Seeing them telemedically doesn't somehow prevent you from then seeing them hands on. It is not either/or.

Another point of advice relates to how you would integrate telemedical visits to clinic visits. If you are seeing patients in your clinic at this time, I would highly recommend that you batch telemedical visits into their own grouping and not interweave them in between in-office visits.

In-office patients are a captive audience. They're in a room, they know that you're out there, and you know that they're in there. Telemedical patients are somewhere out there and although there are virtual waiting rooms that give you both an idea of where each other is, that present accountability isn't the same. Rather than risk running very behind with an in-office patient and then trying to juggle back and forth with your online patients, I would highly recommend you batch your telemedical visits as a group and then your office patients as a group. Perhaps the morning for one, the afternoon for the other, or half the morning for one.

Thirdly, I'll point out that doctors new to telemedicine are likely to experience a unique kind of fatigue that is unique to telemedicine, and if you experience it and understand it, it may be less distressing. Even though it is "easier" to just turn on your computer than to drive into the office and walk around into different exam rooms, there is a fatigue from sitting continuously in front of your screen and not having those different movements to break up your hour or break up your day.

Furthermore, when you are in a room with a patient, all five of your senses are receiving information about that patient. You're working on visual and audio cues, even tactile cues. When you're doing telemedicine, your information is limited to audio and visual and it's only as good as your connection, and that can be very limited. Halting dialogue or a mismatch of sound and mouth can make it much more difficult to get all that information that you took for granted as easy to obtain when you're in the room. You might have even been multitasking in your mind and now you're having to focus so much more intently on a little square on your screen to get the same amount of information to do your decision-making. That generates a different kind of fatigue. If you understand that and are prepared for it, you can find it less distressing.

Rubenstein: That's absolutely true. It does take a little more mental effort. I never called it a fatigue like that, but that you hit it right on the nose there. Dr. Rhee, your advice to people who are starting out?

Rhee: I always start with one of my favorite quotes from Mahatma Gandhi who said that first they ignore you, then they laugh at you, then they fight you and then you win. It's really telling because the story of telemedicine in urology started in 2016. As urologists, we're a secondary specialty, meaning that we're not in the front and center right now. But the point is that we are so needed. Sixty percent of the counties in the United states do not have a practicing urologist. That's a shortage.

Telemedicine for us in the beginning was really about offering access to care in rural areas of America. That really is a big motivator that's been proven with a lot of surveys of urologists. They do this because they feel like it's almost a mission statement to actually provide this kind of care this way. Now, moving forward, here we are today, and this has been the lightning rod. I think the software platforms are very key, I think understanding the patient pools is key, and I think your payers and how you bill are key. But the thing that I think is most important today if you're implementing teleurology is the team.

That team really is about the stakeholders. You need to think about who those stakeholders are in your practice and develop the team first. Look at your scheduler, your billing staff, your clinic staff, and find those champions who you know really are interested in what you are trying to deliver. This will make the next step a lot easier, because I do believe that the government and payers are going to retract some of these easy regulations that have eased off. But you need to be prepared. Like I said before, the genie is out of the bottle.

Finally, remember that the patients are the consumers. This has opened up a market in the industry in terms of delivering telemedical care. We absolutely as providers need to respond to that in a strategic way and in a way that ensures quality as well as affordability. I think we're going to have to figure out different ways to provide care that is an alternative to the status quo that we had pre-COVID.

Rubenstein: My advice, looking at a completely different angle, is finding your regulations and laws, and figuring out what's specific for your individual state. Get every single insurer or at least your major insurers, get every single one of their rules. I always hear about people who want to up-code and are thinking, “Because I'm seeing fewer patients, I'm going to try and do everything I can to up-code and make the patients seem more complex than they really are.” I recommend people don't do that. It is a tough time, it is a challenging time. Let's take good care of patients. Get everything in place, and this will all resolve, given enough time.