The ABCs of Telemedicine: It's More Than Just Picking Up the Phone

Interviewer: Laurie Scudder, DNP, NP; Interviewee: Ernest L. Carter, MD, PhD


September 25, 2017

Editorial Collaboration

Medscape &

Medscape: My name's Laurie Scudder. I am the editor of Medscape Family Medicine. I'm here at the American Academy of Family Physicians Family Medicine Experience (FMX) in San Antonio, Texas. I'm delighted to be joined today by Dr Ernest Carter.

Ernest L. Carter, MD, PhD: I am Dr Ernest Carter. I'm a physician who's been practicing for more than 30 years, and I'm the deputy health officer in Prince George's County, Maryland. I'm also a bioengineer and I've been involved in telemedicine now for more than 25 years.

Medscape: Dr Carter, that's a good segue to my first question, which is: What is telemedicine? We hear terms like "telehealth," "e-health," "virtual medicine." What are all of those terms? Are they all the same or different?

Dr Carter: Telemedicine is an element of medical practice where health information is exchanged via an electronic network to improve a patient's health status. There are a lot of similarities between telemedicine and telehealth. Usually, the term "telemedicine" refers to using that tool to do direct patient care. "Telehealth" is broader and more encompassing. You can do health services using an electronic network. Doing that—for instance, when doing disaster relief, health literacy, even medication reconciliation—represents a broad use of health information over a network. That's typically called telehealth.

Medscape: What are the categories of telemedicine?

Dr Carter: There are three basic categories. The first is teleconsultation. I think that's the one with which most people are familiar. That's the e-visit where there's a two-way consultation from a doctor to a patient. You either use videoconferencing technology or you can do it just by storing an image and sending it to your doctor, with the doctor interpreting it and sending it back. That's a teleconsultation.

Second is telementoring. In that example, a doctor gets mentored by another doctor, typically a specialist, to help them manage a patient. For instance, you have a patient who has autism and you need help. You are in rural Pennsylvania and you need help in managing that patient. You can then connect to an institution like the Kennedy Krieger Institute, where they can have a mentor come online to help you manage that patient without that patient having to come all the way to Baltimore.

The third category is telemonitoring. That's where you get data from a patient who's at home, connected to some biosensor; it could be to a vital-sign monitor, an electronic scale, a glucometer, or any other device that involves monitoring a certain bio-parameter. You're actually practicing medicine with the results that you're getting. You can monitor your patient from home. Those are the three major categories of telemedicine.

The Benefits of Telemedicine

Medscape: What do we know about the benefits, for both the physician and the patient, of televisits?

Dr Carter: One of the primary benefits is that it increases the access to the physician. For my money, that's the most important benefit. It allows the physician to keep in contact and to be able to interact with their patient on a frequent basis. It allows the patient to be able to interact with their doctor from anywhere in the world. That's one of the major benefits.

Another benefit is that it improves health quality. It keeps people healthier, especially if you create your virtual practice and use telemedicine to interact at the right time and in the right place to help that patient stay healthier.

The benefit is that it not only can save money, but it can make money if you know how to set it up right, get your reimbursement mechanism done correctly, and optimize your workflows.

The Nuts and Bolts of Implementing Telemedicine

Medscape: That's the perfect segue to my next question, which is about the nuts and bolts of telemedicine. I'm sold and recognize that it provides a benefit. What are some of the practical steps in implementing telemedicine visits in terms of documentation and reimbursement? How is that done?

Dr Carter: The nuts and bolts of starting a telemedicine practice are, first, to envision what a practice would be like virtually. You need to understand that telemedicine is not a supplemental practice; it is part of your practice. It's not an adjunct or an add-on.

Just like when starting a brick-and-mortar practice, you have to plan. What are you going to do to create your telemedicine practice within your virtual environment? You have to define your scope of work. What services are you going to offer? You have to put a team together that's going to help you do this practice. That means that your staff all have to get together as a team. You have to lead them, and then you have to create an implementation plan. You have to ask, "How are we going to do this?" To do that, you have to create use cases and determine just how you're going to be sure that you satisfy the patient's concerns, that you do this in a time-efficient manner, and that you can get reimbursed.

The three major outputs that you want from your telemedicine practice are: (1) You want it to improve the patient's quality of health; (2) You want it to save time; you don't want it to create more time on you. And (3) It has to make money. If it doesn't make money for your practice, then it's going to be very hard to sustain. Those are the major elements.

Before I end this, one of the things I really want to emphasize is that you have to have a business plan for [implementing telemedicine], just like you do for your brick-and-mortar practice. It is your business. It has to be sustained and it has to work for you.

You need to understand that telemedicine is not a supplemental practice; it is part of your practice. It's not an adjunct or an add-on.

One of the things that you haven't asked me, but which I'm going to tell you anyway, is that this can make your life easier and not harder. Being able to create a virtual practice using telemedicine can make things easier. Some people think that it's going to cause you to have 24-hour-access issues where people are calling you all the time. If you set your practice up correctly, you won't have to be available 24 hours a day. Your brick-and-mortar practice is available for set hours; so can your virtual practice be.

If you want to have other people take your call for you in your virtual practice, you can do that, just like you do with your brick-and-mortar practice. You can't think of telemedicine, this virtual practice, as something that will be a burden on your time. You have to think of it as part of your practice. Once you start to understand that, it really becomes clear how to set it up.

The other thing that is really important about this is that you have to promote patient adoption. Patients are not going to naturally come to this. You have to have a plan for how they can use this service. They won't just come to you and say, "You have telemedicine; can I use it?"

It's just like any other business. This is a service that you offer. Patients have to want it and they have to know how to use it. It has to have ease of use. When you're creating your virtual practice, you have to take into account the technologies that you're going to be able to use to make it easy for patients, and then easy for you.

On your side of the street, your adoption of this service has to not be different from what you have right now in terms of how you do your documentation and your billing. Your electronic medical record and your practice management system have to be the same for your virtual practice. That's incredibly important. Why? If you have two different systems, it takes that much more time for you to do the things you need to do. If you were to create a brick-and-mortar practice, would you set up five rooms using one electronic medical record and practice management system, and another five rooms using another one? No. You have to have the same. That's what is going to save you time. You have to work through the responsibilities and the workflows for each scope of your practice so that when you do [implement telemedicine services], you can have a practice that can actually sustain itself.

Last but not least, you have to create a quality-improvement plan because, just like any other service that you offer, you have to be able to go back and look to see whether it is doing what you thought it was doing. Is it making money? Is it improving quality? Is it saving time?

Medscape: Clearly, this is more than just picking up the phone and talking with your patient. What are some resources you would suggest that physicians who wish to implement this practice can turn to in order to learn from the people, like you, who have gone before them?

Dr Carter: I think the American Telemedicine Association is a great place to start. They have a lot of resources that you can use. The other resource is an absolutely free, government-provided service that has been in this country for a while: the Telehealth Resource Centers. You can go there and talk to people about starting a virtual practice and how to use telemedicine. They have all of the tools and resources that you need when you first start out.

As you create your implementation plan, you're going to find that you will use some of the skills that you already have in terms of creating workflows, but you also are going to need to understand how to create the business model around this service. That takes a little bit of effort, and there are a lot of people who can help you with that.

Medscape: Thank you, Dr Carter. You're one of the people who is helping us with this. We appreciate you sharing your time and expertise with us.

Dr Carter: Thank you.


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