For a small practice or solo physician, launching a virtual care platform might seem like a waste of time and money, especially in a climate where both are in such short supply. But telemedicine offers vital operational and clinical benefits that might mean the difference between a healthy practice and one that goes under.
The trick is in choosing the right service.
“It’s definitely something that has to be well thought out,” argues Wendy Diebert, Vice President of Clinical Services at Vidyo, a telehealth provider. “You can’t just pick one (technology platform) and expect it to work.”
Small practices and solo providers have to think carefully about virtual care considering that they generally lack the resources to experiment and the overhead to survive a failed project. They should not look to replicate the programs in operation at large hospitals and health systems; rather, they should look at their own patient populations, pick a service that can be easily moved online (such as non-acute primary care, follow-up visits or chronic care management), and match the technology to the service.
“There are two key questions small practices need to ask when thinking about incorporating virtual care into their care delivery model,” says Rebecca Hafner-Fogarty, MD, MBA, Senior Vice President ff Policy and Strategy at Zipnosis.
“The first is ‘What problem are we trying to solve?’ Virtual care can help address challenges that range from overcoming barriers to patient access, to supporting patient acquisition and retention, to mitigating physicians’ workload – and more. Answering this question will help the practice and clinician users refine their thinking about what platform will meet their needs.”
“The second question is ‘Who are my patients?” she adds. “We know that different patient demographic segments have varying preferences around how they access care. Understanding who the providers are trying to reach will help inform what access point - or points - are needed.”
Getting Started With Telehealth
According to Lee Horner, CEO of Synzi (the virtual care company spun out of Stratus Video in late 2017), small and solo providers should follow a six-point checklist prior to launching their first virtual visit platform:
- Is it supportable across all devices?
- Will the quality of service be equal to or better than in-person care?
- Will remote patient monitoring be included?
- Is “webside manner” properly addressed?
- Is this as easy as possible for patients to use?
- Are all security and HIPAA concerns addressed?
“You really want to start by looking at your workflow and (determining) how you embed the technology,” he says. Will the platform be compatible with the EHR, or will it create separate processes and cause more headaches than it cures?
Providers may want to choose a telemedicine platform that’s already integrated with an EHR. It gives them a framework from which to work and ensures that medical records are not duplicated. But it also restricts the provider in mapping out the virtual visit platform; with many legacy EHRs developed before the advent of telemedicine, the functions may be limited and at times inefficient.
The other option is to choose a stand-alone telehealth service, such as that offered by any of the dozens of telehealth vendors on the market. Some offer “out of the box” packages that can be easily deployed, while others work with the provider to create a branded service that meets specific needs. The biggest drawback to these platforms is that they may not integrate well with the EHR, forcing providers to either adopt a new medical records platform or maintain side-by-side platforms.
In either case, the platform cannot afford to be clunky.
“Make sure you invest in the right technology that allows you to do the things you want to do,” Horner adds. “You only get one shot at this.”
“It has to be a seamless process,” asserts Diebert, who suggests first sitting down and studying what an actual office visit looks like. “You’re building workflows that mimic current workflows. That takes training and education.”
She also advises providers to check bandwidth and connectivity. A video platform will not succeed if the video is subpar, she points out, and online services that slow down or cut out or cellular connections that drop suddenly will drive patients away.
“You need enough technology to support a good conversation,” says Horner.
Choosing the Delivery Method
“In most states, a video visit is essentially analogous to a physical examination, making this an incredibly flexible option for providers,” Hafner-Fogarty explains. “It offers a wider variety of use cases and supports a broader cross section of specialties. Video may also appeal more to older patients, patients with chronic conditions and others who want to have a more personal interaction with their physicians.”
“Conversely, younger generations may prefer the flexibility of store-and-forward,” she continues. “Video can be challenging from an efficiency perspective. I like to joke that a video-only solution can take a 10-minute office visit and turn it into a 20-minute video visit. Additionally, the effectiveness of video may be constrained by connection speeds and bandwidth availability.”
Horner contends that the video-based platform “is not just a video call.” It’s a complete program that requires the provider to understand the medium and act accordingly. This includes knowing how to manipulate the video camera and how to present oneself to the patient.
“It’s a whole new world,” he observes. “Some are comfortable with video, and some aren’t.”
Horner advises providers to try out the video visit on friends and families first, to get comfortable with the technology and receive feedback. Some even record themselves over several mock visits to analyze their “webside manner” and pick up on problems that need to be addressed before going live.
Finally, Horner recommends selecting a few tech-savvy patients and try it out on them in order to see how they react to the video visit and how the provider reacts to them.
Store-and-forward or asynchronous telehealth, meanwhile, offers different advantages and challenges. This platform allows the provider to create a portal, in which the patient answers prepared questions, enters comments and can even send images. The provider is alerted when that information is available, makes a diagnosis from that information and sends it back to the patient.
Hafner-Fogarty offers four selling points for store-and-forward telehealth:
- It offers excellent clinical efficiency, which enables providers to treat more patients in less time.
- It can also be appealing to providers in rural areas, where broadband internet access is still limited, since it does not require the connection speeds or use the bandwidth of a video solution.
- It also supports all four elements of the quadruple aim, by enhancing patients’ access to care, improving health outcomes through a consistent care delivery, lowering costs and potentially reducing physician burnout by efficiently adding patient encounter documentation directly into the EHR.
- And, the growth of value-based reimbursement and a relaxation of modality-based restrictions for Medicare and Medicaid populations should increase the value of store-and-forward based virtual care for small practices.
“This is a complex answer because it’s not a binary decision; -video and store-and-forward aren’t mutually exclusive,” Hafner-Fogarty argues. “Whether a store-and-forward solution is a good fit depends on things like patient panel make-up, practice goals, and what challenges the practice is trying to solve.”
Privacy and Security
Prior to going live, any virtual care platform that deals with personally identifiable health information has to be tested repeatedly to ensure that information cannot be accessed inappropriately, sent to the wrong devices or locations or stolen.
“HIPAA is just barely good enough,” says Horner, who contends the 30-year-old legislation needs to be updated to better account for health information management via telehealth and telemedicine. “HITRUST is much better, so I’d go for certification there. There are others that are new to the industry, but they don’t really understand the complexity, so I’d avoid them.
Reimbursement and ROI
Reimbursement opportunities for virtual visits vary greatly. Medicare operates under one set of guidelines — and is generally restrictive of how telehealth is used. Medicaid programs operate under a different set of rules, and some states have gone so far as to prohibit store-and-forward telehealth and services delivered by phone, text or e-mail.
“Do your homework beforehand,” says Horner. “Find out what is and isn’t reimbursed before you decide what you’re going to offer.”
Private payers and health plans might offer more leeway, especially if the provider is willing to negotiate.
“There’s been some deliberate efforts to align with payers and embrace cooperation on coverage and reimbursement,” says Nathaniel Lacktman, who leads the telemedicine and virtual care practice at the law firm of Foley & Lardner, LLP, and who hosted a session on this topic at the 2017 American Telemedicine Association conference. “We’re noticeable moving toward that now.”
“Too many sit back on their heels and say ‘We’re not getting reimbursed,’” he says. “But by communicating with commercial payers, they have a chance to align their visions.”
Preparing For the First Patient … And Beyond
Once the platform is established, providers have to get the word out, with messages to existing patients and a publicity campaign for new patients.
“The most common mistake I see in all virtual care deployments is what I call the ‘Field of Dreams’ misconception: the belief that ‘if you build it, they will come,’” says Hafner-Fogarty. “Any new service line, whether virtual care or something else entirely, needs to be supported with education, communication and marketing. If a practice brings on a new provider or adds a new specialty, they wouldn’t dream of not telling people about it. Virtual care needs to be approached the same way.”
Diebert suggests a marketing campaign that highlights how the telehealth platform works and where it might replace the office visit for busy patients.
“Don’t just dump the technology in and expect everyone to know how to use it,” she says. “It’s all about education.”
Scaling Up and Out
Most telehealth and telemedicine experts predict that the virtual care platform of tomorrow will not offer just one technology, but will embrace a variety of platforms, including connected devices and the Internet of Things.
“Remote patient monitoring is going to be big,” says Horner, pointing to the increase in chronic care patients and the need for providers to get in front of that population and manage their care outside the office visit.
While the technology — and reimbursement — are not there yet, providers should keep an eye on how blood-glucose monitors, blood pressure cuffs, weight scales, thermometers and other connected devices are integrated with telehealth platforms. This also includes consumer-facing health and wellness devices like fitness trackers, smartwatches and smart clothing.
“Eventually you’re going to want to connect with these devices,” he claims. “This expansion of the virtual care piece is going to be very important.”
“I believe that virtual care going forward will increasingly be multi-modal,” Hafner-Fogarty says. “This means that not only is virtual care not a choice between store-and-forward and video — it is continually expanding to encompass new modes of access. We’re seeing additional functionalities like real-time chat, AI and peripherals (like wearables and smart speakers) that patients can use to generate high quality clinical data, all of which can be virtual care tools that have the potential to allow clinicians in small practice efficiently deliver high-quality care to their patients, wherever they may be.”