As tools such as online banking, shopping and travel booking have become commonplace, more and more consumers expect the same convenience from their physicians. Telemedicine offers “immense” advantages to patients, says Karen Edison, MD, chair of the department of dermatology at the University of Missouri School of Medicine in Columbia, Missouri. She has been offering telehealth services for more than 20 years and also served as director of the American Academy of Dermatology (AAD) 2019 teledermatology course. “For patients, it’s wonderful because it’s taking care to them where they are,” says Dr. Edison.
Telemedicine can also be a positive for practices and providers. Virtual visits can reduce the rate of no-shows. If patients don’t have to leave work, school or home, they are more likely to keep their appointments. And for lower risk, straightforward cases, physicians can free up valuable appointment time by using tools including videoconferencing, email, Facetime or Skype.
Considerations and Regulations
While modern technology has made it easier than ever to share images and information between patients and providers, there are risks involved. To ensure patient safety and security, practitioners must comply with the Health Insurance Portability and Accountability Act (HIPPA) Privacy Rule. Using office email to send photos and other data is not sufficient. Images and protected health information should be transmitted, collected and stored using a secure platform and encryption to ensure that patient privacy is protected.
Telemedicine laws vary from state to state, so practitioners should become familiar with their states’ rules and regulations. For example, 36 states have parity laws for private insurance coverage of telemedicine; 14 do not, though Alaska, Massachusetts, Pennsylvania and South Dakota are currently considering parity bills. In addition, you can only practice in the state where you are licensed. However, you may apply for interstate licensure through the Interstate Medical Licensure Compact (www.imlcc.org). This allows you to treat patients in more than 20 participating states.
Previously, some states dictated that physicians could not establish new relationships with patients virtually, but with the passage of new legislation in Texas in 2017, all states now allow physicians to connect with new patients via telehealth.
There are several resources to help you track your state’s regulations as well as pending legislation. They include the American Telemedicine Association (www.americantelemed.org), the National Consortium of Telehealth Resource Centers (www.telehealthresourcecenter.org) and the Center for Telehealth and e-Health Law (www.ctel.org).
In addition to reviewing state legislation, physicians interested in offering virtual appointments or healthcare services should inform their insurance carriers to ensure they are covered for these services.
In aesthetic medicine, virtual consults have become increasingly popular among both patients and physicians. “We get patients from throughout the country and all over the world—Canada, Europe, the Middle East, South America,” says Adam J. Rubinstein, MD, FACS, a board certified plastic surgeon in Aventura, Florida. “And the trend is increasing because the world has become an all-access place.”
For virtual consultations, patients make inquiries and share photos as well as their relevant health information through email, Facetime, Skype or specialized software platforms offered on the provider’s website.
Dr. Rubinstein finds that patients seeking body treatments can be reluctant to send photos, as they can be revealing. In these cases, he suggests using Facetime or other video chat platforms. If he is unable to make a clear diagnosis or recommendation after assessing the video or images, he tells the patient he needs to examine them in person first before he can make a treatment recommendation. In all cases, he requires an in-person visit prior to performing a procedure.
“I will not see a patient for the first time on the day of surgery,” says Dr. Rubinstein. “I want to have a chance, in a nonpressured situation, to have a conversation with the patient to answer whatever questions they may have and to make sure they are comfortable and I am comfortable doing the procedure.”
To ensure a positive experience and outcome, the same care and effort should be given to each of your patients, whether they are seeing you virtually or in person. “It can be easy to cut to the chase and talk about the procedure if you’re communicating by phone or email,” says Dr. Rubinstein. “Then you end up with a patient who is not fully informed about the treatment. Likewise, you’re not fully informed about the patient, and that is not a good setup for success.”
As demand for telemedicine and virtual consulations has increased so too have the number of software platforms available to offer these services. Some, such as Zwivel, focus on consultations. Others combine multiple capabilities. Cheryl Lee Eberting, MD, a board certified dermatologist in Alpine, Utah, is the founder and CEO of AZOVA. The technology combines numerous digital health tools and features, including video calls, secure messaging, prescriptions, population health tools, online self-scheduling and e-commerce. Providers can also share records, messages or video calls with other providers involved in the patient’s care.
“People were emailing photos of themselves and their children and asking me to diagnose and treat them over the internet,” says Dr. Eberting. “I thought to myself, wouldn’t that be an amazing opportunity if any physician could have a condition-focused telemedicine clinic and also be able to distribute products and collaborate with pharmacies through their telemedicine technology?”
Since developing the platform, Dr. Eberting has experienced how useful telemedicine can be. Recently she was out of town at a dermatology meeting and a patient contacted her about a possible infection. Instead of waiting to return to the office or referring the patient to another provider, she went online and assessed the case. She then added her staff into the conversation, and they arranged for the patient to have the infection cultured. “I can respond faster and deliver more effective care than I was able to without virtual tools,” she says.
As with any new technology, there are pros and cons to using telemedicine. It can streamline appointment scheduling, decrease appointment no-shows, expand your current patient base and enhance patient satisfaction. But it is not right for every patient. Dr. Edison finds that it is most effective for minor or more straightforward health issues or concerns. Patients with complex medical issues are better served in person. Additionally, she has concerns about patients choosing a provider over the internet vs. going across town and having a face-to-face appointment before committing to a procedure.
Although telemedicine tools can be convenient for follow-up appointments, there are potential drawbacks for surgical patients who travel far from home for a procedure. “No surgeon has 100 percent perfect results,” says Dr. Rubinstein. “There can be wound healing issues, fluid collection or infections.”
He counsels his surgical patients to remain in town for one to two weeks following the procedure so that they are close by the office for the initial recovery process. If they are unable to do so, he tries to limit the amount of necessary postoperative care. “When I know a patient is going to be travelling, then I minimize the number of stitches. Sometimes I can eliminate them entirely just by changing technique and using entirely absorbable stitches,” says Dr. Rubinstein.
Incorporating telemedicine and virtual consultations also involves costs and a time commitment. Practices will need to purchase software, provide staff training and make themselves available outside of regular business hours. “Virtual consultations are done outside of regular hours and they require a bit more of a time commitment,” says Dr. Rubinstein. “I wouldn’t say it’s overwhelming, but you have to have the staff capacity and your own capacity to spend a little extra time if you want to offer these kinds of services.”
Meeting the Demand
Currently, the demand for virtual health services far exceeds the number of physicians who offer them. If you are interested in investigating telehealth, “A great place to start is the American Academy of Dermatology (AAD) teledermatology toolkit,” says Ivy Lee, MD, of Pasadena Premier Dermatology in Pasadena, California. AAD members can access the online toolkit at www.aad.org>Practice Management Center>Managing a Practice>Teledermatology.
Physicians of all specialties will benefit from asking some initial questions before they begin investigating telehealth options:
- What type of telemedicine services do you want to offer your patients?
- Do you want to provide store-and-forward capabilities?
- Do you want to provide virtual live-interactive (videoconferencing) appointments?
- Do you want to work with referring providers directly through telemedicine?
- How do you want to implement this in your practice?
- How does this fit with your current electronic medical records system?
- Does your current electronic medical record system have telemedicine functionality?
“For the future of our specialty, I do think we need to be more available,” says Dr. Edison. “The dermatologist of tomorrow will be doing more teledermatology than we are today.”
“Patients love it when they’re able to engage in telemedicine with you,” says Dr. Lee. “If you want to continue to have a thriving practice, it is worth considering how to meet the growing demand for virtual health services.”
Stephanie Kramer is a freelance writer who specializes in healthcare topics.
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