Breaking Down Telehealth Barriers in Your Practice

Step 1: Offsetting Costs

Grant opportunities may support a one-time capital cost. The Federal Communications Commission (FCC) has a Rural Health Care Program that funds telecommunications and broadband services. Other governmental and non-governmental organizations have grant funding available that supports telehealth initiatives. The Rural Health Information Hub provides a library of grants available by geographic area and nationwide that you can filter by the telehealth topic. The Health Resources and Services Administration also provides information about available grants. Local non-profits, hospital foundations and community agencies are additional resources that can be used to find grant opportunities.

 Costs associated with implementing telehealth care

• Technology
  • Your EHR
  • Hardware (webcams, speakers)
  • High-speed internet
  • Tech support (as needed)
• People cost
• Process cost

 Factors that can offset telehealth care costs

• Makes practice more competitive
• Improved reputation
• May increase market share
• Decrease in no-shows/late cancellations
• Improved patient satisfaction
• Decrease risks of travel
• Work from home with decreased overhead in a space-limited clinic
• Originating site fees if hosting specialty telehealth visits provided by a referral center’s practice
• Potential for financial incentives (for better chronic disease management if participating in shared risk payment models)

Step 2: Managing Billing and Coding

In 2021, medical billing was revised to account for total time as well as medical decision making (MDM) on the day of the face-to-face encounter. This includes the following:

• Reviewing the patient’s chart before the appointment
• Obtaining and reviewing separately obtained patient history
• Performing the examination
• Counseling and educating the patient
• Ordering medications, labs and procedures
• Communicating with other healthcare professionals
• Updating the documentation in the patient’s medical record
• Interpreting results and then communicating them to the patient/family
• Care coordination

This is a summary of 2021 Office-based Evaluation and Management (E/M) changes from AAP News:

AAP has a high-level summary of changes to billing, based on medical decision making, in 2021 Office-Based E/M Changes and a more detailed summary of MDM Chart and Changes with a table of MDM Charts to download. Here’s a quick overview:

Step 3: Ensuring Payment for Services

Currently, payment for telehealth services continues in parity with in-office visits. There are some exceptions, however, thus it is recommended you connect with your local professional organization for more information on telehealth payment:

• American Academy of Pediatrics Chapters
• American Academy of Family Physicians Chapters
• National Association of Pediatric Nurse Practitioners Chapters
• National Rural Health Association

It is also highly recommended that pediatricians know their state's Medicaid telehealth reimbursement policy.

Step 4: Introducing Technology and Training

Education can help garner commitment to a telehealth program from partners and staff. Here’s how:

• Provide some guidance on the use of devices and apps that you have in place for telehealth visits.
• Have a telehealth template near your telehealth visit station. This could include step-by-step instructions, reminders about privacy and consent and tips for good “webside manner” that makes patients more comfortable with a video visit.
• Other tools to employ with the launch of your telehealth program are videos and slide presentations that you use for mandatory in-service training.

Remember to seek continuous feedback as everyone learns the new system and finds room for improvement. Also, assign roles for walk-through, check-in and tech-support that mirror in-person visits:

• Front desk staff could walk families/caregivers through accessing the telehealth link prior to the visit. They should ask families if any accommodations are needed to support accessibility of the appointment.
• The nurse can check the patient in and update them on wait times.
• Someone who is more comfortable with technology can sit in the room during the telehealth visit to assist when needed. Make sure to introduce them to the family/caregiver and patient so they aren’t surprised to meet a new face.

Finally, always have a backup plan. Issues with technology will arise. Do you have an alternate link, or can you move the video visit to a phone visit? Make a plan and communicate it to your partners and staff.

Step 5: Documenting in EHR

Video visits can facilitate many aspects of a physical exam. With the help of a family/caregiver using a webcam and flashlight on the other end, you can make meaningful observations. Documenting the visit is important for billing. Here’s sample documentation from a video visit:

Sample Physical Exam Documentation

Location/Environment: ***

General: Alert, well-appearing, interacting in an age-appropriate manner

Skin: No pallor, rash or ecchymosis (parts visible)

Head: Normocephalic/atraumatic. Anterior fontanelle appears flat, soft, and non-bulging (caregiver observation)***

Eyes: PERRL (observed construction using light source). EOMI (follows objects in four directions). Sclera are white, not injected. Conjunctivae are pink, not erythematous or pale. Lids and orbits are normal appearing. No ocular drainage visible on lids/lashes.

Ears: External ears appear normal, no obvious swelling or erythema. No visible drainage from ear canals. Manipulation of tragus/pinna does not elicit pain.

Nose: No obvious rhinorrhea or nasal discharge. Nares patent. Breathing through the nose observed with closed mouth.

Mouth: Moist oral mucosa. No oral-mucosal lesions visible with light shown in mouth. Uvula appears midline, tonsils symmetric, grade I/II/III+, pink without exudate.

Neck: Normal flexion, extension, rotation. No visible external masses.

Cardiovascular: No cyanosis, mottling or pallor. Capillary refill < 2 seconds.

Respiratory: Normal work of breathing. No nasal flaring, subcostal, suprasternal or intercostal retractions. No audible stridor or grunting. No coughing. Pt speaking in sentences without difficulty (if verbal)***.

Gastrointestinal: Abdomen appears flat and non-distended. No tenderness apparent with supervised palpation to four quadrants of abdomen. Stool normal appearing.

Musculoskeletal: No visible deformities or swelling of joints or extremities. Moving all four extremities normally. Bearing weight without difficulty. Normal gait observed.

Neurological: Alert, interactive and age appropriate. Symmetrical facial movements, no nystagmus, no amblyopia. Verbalizes normally with normal voice quality. Normal activity and strength. Coordination grossly normal. Observed walking, reaching across midline, grasping objects.

Some markets also require a standard phrase, with details of how the telehealth visit was conducted, be included at the end of your note. If your state/market requires this, here is a sample phrase that could be used:

The following modality (e.g., live audio/video connection, telephone) was used to conduct this live telehealth visit: _____.

The patient attended remotely from [Location] while the physician attended from [Location]. Prior to the appointment, the patient or their guardian provided us with informed consent to conduct this telehealth visit. On the day of this telehealth visit, I spent a total of ___ minutes on this patient’s care. This total includes medical decision making and preparation before the visit, the time spent examining the patient and any post-visit care coordination conducted on the day of the telehealth visit.

Step 6: Thinking Outside of the Box

Telehealth not only functions as an option to see patients, but it also opens up a world of possibilities that can enhance your practice by allowing you to:

• Integrate behavioral and mental health
• Integrate lactation consultants and care coordinators
• Invite subspecialists to “beam” into your clinic
• Provide virtual care to a school or daycare center
• Monitor medically complex patients at home
• Offer teletherapy services like physical therapy, occupational therapy and speech therapy

Telehealth could also enhance care in a hospital setting by:

• Including family members in family rounds who would otherwise be unable to attend
• Including the PCP perspective in inpatient care conferences
• Engaging in consults from children’s hospitals with neonatologists and pediatric intensivists, for example
• Managing pre-transport stabilization with pediatric emergency departments
• Conferencing with a referring institution prior to discharge

These are just some ideas that are already possible. After you’ve integrated telehealth into your regular practice, you may find extending your telehealth services will positively impact the wider community.