Getting Started in Telehealth

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Getting Started in Telehealth

A variety of telehealth applications can be leveraged by a pediatric medical home. These tools are rapidly expanding with the advent of improved connectivity and the decreasing cost of the technology.  Examples include;

  • Medical or behavioral consultation directly in the office, allowing the practice to truly be a coordinated medical home and enhance access to services for their patients and families
  • school—based teleconsultation
  • home video consultations
  • integration of biometrics from an individual's wearables and apps, and the use of algorithm- based asynchronous e-visits
  • participation in educational and research activities

​As these tools become more available, it is increasingly important to assess the needs of a practice and its patients prior to implementing​​ a telehealth service. Telehealth offerings within a primary care practice can be an important tool to support coordinated care, as well as meeting the needs of patients.  Regardless of the modality, there are some common planning elements worth considering for any teleh​​​​ealth effort, which will be explored in this section.

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Assessing the​​​ Needs, Goals, Resources

The initial phase of any telehealth project includes assessing needs, setting goals, and identifying the resources. Establishing a broad-​​based support team is essential to the successful identification, development and implementation of the program. Following are key team members:

Adminis​​trative Champion:

    • Responsible for managing contracts, communicating with and recruiting the telehealth partners (typically vendors, insurers, or service providers) and identifies office personnel support roles. This team member may also be responsible for identifying any regulatory issues regarding the use of telehealth in their region. View sample job description.

Financial ​​​​Champion

    • Responsible for understanding the costs and revenues, formulates the business plan and monitors the financial dynamics over time.  It is crucial to have a clear understanding of payment for telehealth in the region.

Clinical Champion(s)

    • Responsible for identifying clinical support needs, training needs for staff in telehealth work flow and procedures, defining the workflow of telehealth encounters, developing and approving care protocols, and monitoring clinical quality over time.  This member should also be well versed in local and national the telehealth policies and regulations.   

Technical Champion

    • Responsible for assessing bandwidth and equipment needs, explores integrations with existing telehealth systems in the region, medical records, scheduling and payment systems, participates in installation and ongoing training in the use of the technology.

Once the team is formed, the team should establish/utilize a checklist of activities required before launching.  It is also helpful to identify a start date to assist the practice with preparing for these transitions in the workflow.  A "soft go-live" is helpful as this​ can help the team to work out unexpected kinks and receive feedback from the office on the processes in advance of the true start date (see template on page 3). The AMA Steps Forward Initiative also includes a downloadable checklist forprimary care providers or specialists. 

Example Start-up ​​​​Checklist: Connecting a Specialist to a Private Practice

​Administration
 Completion DateNotes
Establish administrative contact for the service​  
Identify initial presenting sites/rooms   
Identify scheduling parameters (eg. Mondays from 2-4 pm)  
Create EHR scheduling templates  
Develop a Memorandum of Understanding (MOU) that deliniates the responsibilities of each site  
Obtain Signed MOUs from each site  
Establish presenting site administrative contact  
Financial  
Identify consultants and develop contract  
Identify need for presenting site resource payment  
Establish preliminary business plan  
Clinical
Establish provider champion  
Establish contact to approve consults for telemedicine  
Establish presenting site clinical champion  
Identify tele presenter needs  
Create presenting site clinical protocol  
Identify follow up procedures  
Create emergency plan procedure  
Establish mechanism to assure identity of patient and provider  
Train tele presenters on process and role as advocate for patient  
Quality assurance evaluation tools in place  
Technical
Assess bandwidth availability  
Assess need for examination peripherals  
Assess presenting site room for optimal encounter experience  
Assess consulting site equipment needs  
Equipment approved, ordered and installed  
Equipment Training  

Consultation​​ on Contracts

Legal consultation for any telehealth contract is recommended.  If the telehealth effort is connecting two health provider organizations, a particular focus Stark and anti-kickback laws (www.oig.hhs.gov) is essential.  If the intent is to enable the rendering of care through prescribing, a review of the state's prescribing laws should be undertaken. 

Busines​s Planning

The viability of a telehealth venture often depends on the payment model which the practice is engaged in with insurers.  The service may be reimbursable in a fee-for-service environment depending on insurer (view state laws and reimbursement policies).  However, the insurer or parity legislation may have caveats as to the site of the patient/provider, type of telehealth used and may be constrained by certain billing codes (view states with parity laws for private insurance coverage of telemedicine​).  In addition, the added overhead required in some approaches to telehealth may make it less worthwhile compared to in-person visits if not offset by efficiency improvements and increased access.   In a cost-sharing environment, such as an Accountable Care Organization, telehealth has greater potential for improved margins over in-person care for the same reasons it may fall short in a fee-for-service environment. Leveraging this potential may require negotiation with the insurer or health system if a telehealth policy is not already in place. 

At the core of planning a telehealth venture is a sound business plan.  However, this aspect can easily be marginalized due to the exploratory nature of introducing new technologies into the care system.  Time spent establishing a solid business plan is therefore particularly essential.  The business plan should reflect the overall goals of leveraging telehealth technologies. It should also be a fluid plan that is adaptable should new opportunities or challenges arise with the application of telehealth.   Following are some essential elements of a telehealth business plan:​

Typical Elements of a Telehea​lth Business Plan
  • Summary – Goal(s) of telehealth program
  • Identifying need and the market​​
  • Describe the service
  • Identify internal and external stakeholders for inclusion
  • Assess for resources and additional investments needed
    • Technical support
    • Training
  • Marketing
  • Technical maintenance and upgrades
  • Assessment plan
  • Budget, to include all expenses, revenues and predicted downstream impact


Lia​​bility

It is important to keep up-to-date on the liability rules and regulations. Information can be found at the Center for Telehealth and e-Health Law and the Center for Connected Health Policy.

​Licen​sure

The American Telemedicine Association (ATA) captured the policy landscape of 50 states with 50 different telemedicine policies, and translated this information into a report that extracts and compares physician practice standards for telemedicine for every state in the U.S. ultimately assigning a grade which indicates existing policy barriers that inhibit the use of telemedicine that would enable patient and provider choice to quality health care services. View the report here.

​Clinical Tel​ehealth Parameters

First, the practice must decide on the telehealth visit parameters, including which conditions will be seen, ages, a clear process for referring for in-person care and additional diagnostic testing, a process for handling of emergency situations, and identifying exclusion criteria dependent on assessment capabilities and comfort of the provider. The ATA developed guidelines for live, on demand, Primary and Urgent Care.

Selecting a technology platform

Selecting a technical platform for the telehealth effort requires careful consideration. Before assessing platforms, it is important to define the needs of the technology to help achieve the stated goals. Consider including elements that are required for success as well as considerations for growth and expansion of the effort.  Clearly articulating expectations of the telehealth program goals will assist the vendors of platforms in providing a product that will lead to satisfaction. It is vital to ensure that the platform:

  • HIPAA Compliant (obtain documentation)
  • maintains sufficient connectivity
  • establishes minimum bandwidth needed by platform and location
  • offers available necessary bandwidth at peak times
  • prompt speeds for upload and download capabilities

In addition to upfront costs, there are also ongoing costs that are associated with:

  • Warranty
  • Services
  • Upgrades

When shopping for the platform, ask for references from practices similar to seek input on the vendors strengths, weaknesses, and compare platforms relative to competitors. 

The most important driver of selecting a platform should be the predetermined goals of the objective, which will help avoid which can lead to excess expense or frustration with the platform.

The AAP Technical Report on Telemedicine (2015) provides additional information on technology choices, including consideration for the type of telehealth provided (synchronous versus asynchronous), need for peripheral examination devices and use of standards-based video conferencing.   

​The following resources are available when selecting equipment (videoconferencing and peripheral)

Preparing​​​ Staff/ Staff Training 

As mentioned above, staff support and buy-in will be key. Identifying those champions early on will help mitigate concerns among staff on operational process changes. During the planning, it is essential to identify how telemedicine will fit within the practice workflow. Some questions to ask, include:

  • When will the telemedicine visits occur? A certain day of the week? Time of day? On-demand?
  • Will there be a dedicated room where the telemedicine visits will occur?
  • How will staff make this work with the workflow?

Be sure that the staff are properly trained in using the telemedicine equipment and are comfortable with the new service offering. Additional information on training, can be found here.

​Documenti​​ng Telemedicine Visits (In and Out of EMRs)

  • Language for billing requirements
  • Telehealth codes
  • Documentation requirements for telehealth
  • Language to confirm presence of telepresenter and assistance offered, if applicable
  • If multiple sites in a consultant to primary care relationship, records typically maintained at both at both patient and specialist sites.  A software or cloud interface may allow documentation between sites.  In this case it is important to build into workflow or automate the transfer of documentation to the applicable sites.  In the event of a review of records, the full record would likely be considered documentation from all sites.

Marketing it ​to patients (see template letter)

Alerting patients that this service is now offered is a critical step.

​Telehealth Resource​​ Centers

Telehealth Resource Centers (TRC) are supported by the U.S. Department of Health and Human Services' Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth. TRCs provide assistance, education and information to organizations and individuals who are actively providing or interested in providing medical care at a distance. Find your regional TRC here. ​

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