Introduction
Incorporating telemedicine into your practice is not a one-size-fits-all solution. Preconceived notions of what telemedicine is or what it should be may prevent many from venturing further. Technological complexity and the number of technologies that are available will likely continue to follow a trend similar to Moore’s law, (that the number of transistors on microchips will double approximately every two years, and that technology will become faster, smaller and more efficient as time passes). Planning for the provision of telehealth and predicting what exact technologies will next reach prime time in healthcare seems an arduous task; but there is a useful rubric or list which can be used, to help the urology practice deciding how to plan their telemedicine offerings (also see Fig. 3.1 ):
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Teleconsults: new patients and or established patient consultations
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Digital diagnostics
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Telemonitoring or remote care
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Wellness monitoring for preventive care
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Digital health interventions
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Teleprocedures
Each of these will be discussed in more detail in the coming chapters but briefly; teleconsultation or teleconsults are considered by some to be “hands-free” medicine. They are considered by some to be most suited for follow-up encounters rather than initial encounters; however, this need not be the case for every type of consult. While the importance of physical examination to clinical medicine can and should never be diminished, there is growing commentary that suggests it is often neglected in modern medicine, and telehealth offerings will likely add further to this trend as they have not yet solved for this. The point of saying this is that a useful starting point is to consider which patients, which physicians, and which consults are most appropriate and perhaps better served by a teleconsult. This work can begin with a simple audit of visits, or survey of patients at your clinic, to establish if patients would have been happy to have completed their visit, or their next visit by a teleconsult. This is a low effort but high-return activity and will better prepare both practice and patients for such a service. A study from the Department of Urology in a Veteran Affairs hospital in the greater Los Angeles area, which was conducted pre-COVID-19 pandemic in 2015, reported 95% of patients report their care via telehealth as “very good” to “excellent” ( ).
The opportunity and the challenge
For many, telehealth has been or will be the insertion of a webcam into their consult room. It may be the insertion of a webcam into a room that wasn’t intended to be a consult room, or it may be replacing the act of walking from waiting room to consult room, with a webcam—the “webcamification” of a practice. It can be so much more, and this change offers a wonderful opportunity: any practice habits that have been in need of change or improvement can now use this moment to enact this change.
Consider the practice where the workflow might see a patient approach the registration desk, meet the administrative staff member, check in, receive a clipboard of questions to complete, including demographic information, past medical history, and billing information. The patient is reseated, completes the information, before returning to the registration desk to hand off this information to the administrative staff and confirm their identity with an acceptable form of ID. The admin then reviews and transcribes the information into the electronic medical record (EMR). The patient will be called and see the practice nurse for triage, measurement of vital signs, weight, height, and collection of clinical samples, before being reseated and before finally moving to see the advanced nurse practitioner/physician assistant/physician.
Telehealth provides the opportunity to make this process more efficient: to reduce the start-stop journey of the patient on a typical clinic visit, to eliminate administrative staff transcribing information, and allow them to help verify information instead of placing them in a position where they make transcription errors.
Addressing disparities
Despite improvements in terms of access, there is a risk that telehealth can exacerbate disparities: not everyone has a reliable internet connection, or the correct tools to participate in a telehealth consult. Not everyone is comfortable or tech-literate. The solutions here are often generational, and indeed not new. Not everybody can just pop in to their local hospital; prior to telehealth, there were (and still are) vast swathes of people who did not have access to healthcare by mere virtue of proximity. Telehealth is not a prescription for distrust or mistrust of the healthcare system. It can provide a part of the solution, but it is not the panacea. Government policy and healthcare delivery will need to keep pace and evolve. Fee for service models where urologists are reimbursed only when a patient comes into the office, when the clinical team physically examines, performs a test, completes procedure, or writes a prescription will need to be reexamined. Many already find this model unfit for the purpose of improving patient’s health, and the broader offering and delivery of telehealth offers the opportunity for practices, as large stakeholders in this process, to help redesign and improve the healthcare system of which they are a part.
Telehealth offers all urologists in practice with an opportunity they are not otherwise offered. Urologists can look at their practice, and design anew, how they want to provide and care for their patients; with due regard provided to those who come from a poorly served group who have had physical, language, systemic, or other barriers to their care provision.
Payments/reimbursement
While differences exist in healthcare models, much of contemporary urological telehealth prior to the COVID-19 pandemic was being offered by subscription health services offering care for preselected urological issues, such as erectile dysfunction and the medical management of lower urinary tract dysfunction and incontinence. The service a practitioner provides need not conform to existing models requiring insurance preapproval, nor must it be a subscription model only, caring for one or a few cherry-picked urological complaints.
At present, and in part due to COVID-19 emergency health measures, reimbursement for urological care provided by telehealth is typically reimbursed by insurance companies in the same way as in-person visits. It is hoped that reimbursement in much the same way can be continued once this emergency ends. Reimbursement is discussed in more detail later in this book.
Implementation and strategy
Provider and staff training
For those confident with digital systems, and troubleshooting software and hardware issues, at least an hour of preparation and training with the various tools that will be employed for a telehealth visit is required. For those less familiar, more resources and guided education are often beneficial. Where training must end, a mock consult or training consult will give everyone the opportunity to test out the workflow, become familiar with operating systems, and help provide confidence to staff, who will in turn help troubleshoot for patients and give patients greater confidence in using new and sometimes unfamiliar technologies.
A suggestion for getting started is to have a “soft” launch, where all staff and not just providers can gain confidence and troubleshoot any issues without usual time constraints. Although telemedicine is often built as a physician platform, it is prudent to include the front desk and nursing staff within the telemedicine model to mimic a standard in-person encounter. I would suggest that for the first week or for the soft launch for inexperienced practices, all telemedicine visits are limited to 30 min for both new and return patient visits. Once familiarity and competence are demonstrated, providers can choose to adjust their clinic attendance to better accommodate patients.
Patient education
Office staff will spend time upfront to present the option of a telemedicine visit to patients and coach them through the necessary software for the first encounter. Patients will be made aware of potential advantages of the telemedicine visit such as not postponing their healthcare needs while staying safely at home, having the ability to save travel and waiting times, and avoiding the expenses associated with transportation and parking. I would suggest nursing staff should call patients approximately one week ahead of their appointment to confirm their preferred method of audiovisual communication or that they are prepared to use the platform your practice prefers to use. It’s also useful that they explain the procedures ahead of time so patients are prepared.
Further, I would suggest that shortly before the scheduled telemedicine appointment time, a member of staff should confirm the patient has successfully connected and they may also perform a review of requisite materials and information for the visit. In many respects, one should conduct the visit in the same sequence as they find productive during their in-person clinics where admin or front desk staff can ensure they have the patient details for billing and follow-up, nursing staff can review the patient’s history, medications, allergies, and collect or review any measurement from connected devices. Such processes will often be familiar to your patients and can act to make the visit seem more familiar, and patients will be less apprehensive about things going wrong when they’re talking to their physician.
Optimize your medical record system
The documentation requirements for a telehealth service are the same as for a face-to-face encounter. The information of the visit, the history, review of systems, notes on the consultation, or any information used to make a medical decision about the patient should all be documented. Whether or not you utilize an electronic health record, having a system in place where each of the staff can review and record details as part of their workflow and allow the chart to be available for the next user in the workflow is something that can and should be planned for. Adopting and using a separate telehealth-only electronic notes system, is not something which I currently can recommend or see particular value in. If you are relying upon telehealth devices or measurements, some may come with their own platform or cloud-based interface; it is wise to have a system in place to document these as they are reviewed, and store a copy of the results directly in your (electronic) medical record.
Depending on the context of the care provided, it may also be important to prepare workflows to ensure adequate documentation for reimbursement. For example, some health insurers require documentation of a certain minimal set of data before they will reimburse providers. The following list includes examples of each of these, along with sample text one might find helpful:
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Patient consent should be documented. Very often providers must document confirmation that the patient agrees to receive services via telehealth—even verbal consent, but it must be documented.
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The method of telehealth (for example: Consultation was performed via secure two-way interactive video connection over ____ [insert video platform name here] ___).
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Provider location. (For example—The provider was located at __ [clinic, city, state] __).
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Patient location and disposition. (For example—The patient was located at __ [city, state]__).
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List all other clinical participants, roles, and actions. (For example—Consultation with ___patient__, with ____RN___, who reviewed the patient’s medical history, medications, and allergies, and obtained vitals and patient weight; and ______MD___ who conducted the physical examination and consultation with ___ [the patient]__).
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The amount of time spent discussing the medical reason for the consult, and often may require start and finish times if a service was offered. (For example: The consultation including discussion of treatment options lasted 30 minutes. In addition, a 15 minute counseling session on smoking cessation was also provided by ____RN___ and started at 9:15 a.m., and concluded at 9:30 a.m).
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Other documentation requirements are the same as a face-to-face encounter.
Patient and provider investment in hardware
While most practices will have some computer equipment, to begin a telehealth practice, you may need to invest in some additional hardware. This includes desktop computers, laptops, and smartphones. For telehealth visits, and particularly if existing desktop computers are older, you may need external webcams or speakers. While approximately 86% of the population of the European Union have a smart phone, ∼85% in the United States of America, and ∼75%–80% in Australia and South Korea, one should not assume their patients will have both a suitable device and a suitable internet connection. While advocating for greater patient access should remain a priority for all who pursue the provision of better and more equitable healthcare, it is now evident that the majority of patients in such nations will already have a suitable device and connection, whether a laptop, tablet, or suitable cellular phone.
Billing and coding integration
Implementing telehealth requires a thorough understanding of eligibility, terminology, and billing. Approval and documentation requirements for telemedicine visits differ by classification, and familiarity is essential for coding and billing compliance. Virtual services include telemedicine visits, virtual check-ins, and e-visits.
Telemedicine visits (aka video visits) allow patients to interact through the necessary elements of both live and interactive audio and video. This can be used for both new and established patients as well as patient consults. The billing and documentation can be considered the same as for in-person visits, and so have the highest revenue potential.
Clinician phone visits are scheduled, telephone (two-way live audio)-based encounters between the patient and provider, and not originating from a related emergency medicine service provided within the previous week, or leading to an emergency medicine service or procedure within the next 24 hours. New and established patients can use this option (as a result of a recent change). These visits are billed according to the time spent in direct telephone contact.
A virtual check-in is a brief, non-face-to-face encounter between a patient and a physician that use digital communication technology. Eligibility requirements for virtual check-ins are less stringent than for telehealth visits, and documentation requirements are also less extensive. It may be a brief telephone check-in call with an established patient between a physician or advanced practice provider to decide whether an office visit or other service is required. These have a minimum duration of 5 min in direct contact. These contrast with a “remote evaluation of recorded video and/or images” submitted by an established patient, and where the visit has not originated from an emergency medical visit within the previous 7 days or lead to an emergency services or other procedure within the next 24 hours.
E-visits contrast further as they are non-face-to-face encounters between a patient and a physician that use asynchronous (not real-time) digital communication technology. E-visits are for established patients who have had an appointment at most within 1 year prior, and the entire consult occurs via a digital platform—like a secure patient chat or the secure patient portals many may be familiar with in electronic health records. E-visits cannot be used to relay results or schedule appointments but can be used for digital evaluation and management.
Information technology support
As with the adoption of any new process, procedure, or technology, there is always a learning curve. While urologists are well accustomed to learning curves from their own professional development as multiproceduralists, a similar learning process can and should be adopted for implementing a telehealth service. Obtaining mentorship and maintaining supports in the form of those more experienced in telehealth systems, whether other colleagues or IT support, is particularly important while practices and physicians navigate their way along the learning curve of telehealth provision.
Audiovisual platforms
For those at institutions, many will already have agreements in place with a video conferencing or teleconsult service, and some may already have integrated these services to their electronic medical record (EMR). There are a number of online providers who have Health Insurance Portability and Accountability Act (HIPAA) and General Data Protection Regulation compliant services for medical video consultations. Important considerations when choosing a provider include network reliability, ease of use for patients, and those providers that do not require patients to have an account. Some widely used platforms are Doxy.me and Doximity.com , which offer features such as a text message sent to the patient’s smartphone device, and a single link will permit them to start a video chat with their provider. In the United States, there are temporary waivers for HIPAA, which permits the use of other noncompliant platforms, but one doesn’t need to transmit confidential patient information or leak even more metadata to such tech behemoths, so one should not.
Patient and caregiver participation
It is imperative that regardless of the modality used to interact with patients, healthcare remains patient-focused. While many urologists might spend a great deal of time and resources focusing on their own ability to provide this service to patients, one should consider better ways to perform a teleconsult and enable better uptake for certain patients—particularly those who may require in-home support or the help of caregivers to facilitate their visit, whether in person or online. There is a need to consider your “webside” manner as well as your bedside manner.
Deciding what services to offer
A useful metaphor for deciding what services to offer, is considering how urology trainees acquire surgical and other skills. Start with relatively simple procedures which help gain confidence in fundamental principles, including developing confidence and competence in using tools, and troubleshooting when things don’t work as they should.
As confidence is gained, one can gradually, and in a step-wise fashion, introduce more complex procedures to their telehealth practice. A sample framework of services is listed below. This should be considered a general list, but individual practices may weigh technical, workflow, and change management differently and so these may be different for your practice.
Providing telehealth (audio and video) visits to patients for routine follow-up of noncomplex conditions.
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Requires relatively little new hardware
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Many are already familiar with these technologies
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Patient and physician already have an established relationship
Incorporate e-prescribing to your care
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Integrating the practice into your workflow and documenting and billing as appropriate
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Many patients are familiar with the concept of prescriptions being “called in” to a pharmacy for them, but some may require additional prompts or follow-up to make sure they remember to collect the prescription and start therapy
Telehealth visits to new patients, where the presenting complaint is unlikely to be complex or complicated.
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This may require changes to practice workflow, particularly administrative work, collecting new patient’s details, and obtaining various consents.
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Guiding staff and ensuring buy in may take some time as many are often reluctant to adopt change.
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It is also important to remember that not every visit is suitable for telehealth care; this step will allow for providers to gain confidence in knowing when to convert a televisit, to an in-person visit, and all of the steps, from counseling the patient to scheduling and coordinating with other staff, to arrange for an in-person visit.
Incorporate remote patient monitoring of chronic conditions for patients who have had a relatively stable condition, or where the course of their disease has been relatively predictable.
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Introducing new hardware to patients and incorporating hardware, software, and other IT integrations that may be required are often best performed in the context of caring for patients with relatively stable and chronic illnesses first.
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This will also likely introduce more workflow complexity, and initially may require additional time to review information either before or during the visit.
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Increased administrative complexity and introducing staff to new billing procedures/billing using codes not used before may be required.
Incorporate remote and digital diagnostic procedures to your care.
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Introducing new technology, but where the provider and patient depend on a reliable and consistent result, and for it to be provided immediately and in realtime during the consult, introduces all sorts of complexity. It is best added after similar issues have been overcome by all members of the medical practice.
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Staff will be becoming more familiar with changing and new administrative and billing procedures, as well as documentation requirements
Offer telehealth visits to all patients including those requiring coordination of multiple diagnostic procedures and investigations, and which may require multidisciplinary input.
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Trying to provide technical support for your own office, the patient and colleagues can be overwhelming. Complexity can be reduced by reducing the odds of either your practice or your patient having an insurmountable technical issue during such consults. This can be achieved following a gradual and stepwise introduction of the tools and technologies to all stakeholders in healthcare.
Bibliography
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