This module will address topics related to how a telemedicine
service is established or developed and operated. In particular,
it will focus on medical specialty consultation services provided
via telemedicine where a medical specialist in any of a variety
of fields from allergy and asthma to urology is involved with
examining, diagnosing and treating a patient at another
geographic location. Telemedicine is just one of several aspects
of telehealth. If you are interested in home telehealth services,
such as home monitoring, using telehealth technologies for
distance learning or training, teleradiology, remote ICU
services, telepharmacy, school based services or other types of
services not listed here, you will need to consult other modules.
This module is intended to address the concerns and questions of
organizations and providers who are interested in offering
telemedicine services either within their own organization, to
other medical care settings or even to individual patients. It is
not intended to provide information to assist those who may be
seeking health care via telemedicine.
This module is intended to provide assistance to those who are
interested in establishing and operating telemedicine services
for specialty consultations and direct patient care services,
such as psychiatric evaluations, remote infectious disease
evaluation and diagnosis, review and evaluation of pediatric
echocardiograms, evaluation and treatment of skin conditions,
genetic counseling, psychiatric medication management, to name
but a few examples. The module will provide information about how
to determine what kinds of services can be offered, how to obtain
the support of a parent organization, how to organize the service
within the parent organization, how to establish remote sites
where patients are seen, how to execute the consultation process
and how to maintain and improve the quality of that process.
View each section of this module by topic, at right
»
A telemedicine specialty consultation service is one that
provides care to patients or advice to other medical providers in
a particular medical subspecialty or healthcare specialization
where the recipient of that service is located at a different
geographic location from that of the provider. Typically, such
services originate from health care systems, hospitals or large
medical group practices that employ a diverse collection of
expert and highly experienced medical and healthcare specialists.
The specialists communicate with patients and/or providers at
physically separate locations using a variety of communications
and information technologies and tools to exchange medical
information. These technologies may range from complex live,
interactive videoconferencing with associated examination devices
to simple image capture and transmission for storage and review.
The specialist examines the patient, may or may not order
additional diagnostic tests, may or may not provide direct
treatment, but generally creates a consultation report for the
referring physician. The specialist is typically reimbursed the
same amount as if he or she had seen the patient in his or her
own office.
Such services are typically organized into three components with
overlapping responsibilities – clinical care, technology support,
and administration. However, before these components can be
developed, it is important to understand and plan for how the
services “fit” within the organization providing them.
What do I need to do to get started to establish a telemedicine
consultation service?
A successful telemedicine consultation service involves a
significant amount of work in several areas. It requires that the
offering organization formally support the service in terms of
organizational “buy in” from senior management, clinical
department heads, physician and other medical specialists, as
well as the legal and billing departments.
What kind of central staff do I need for a live, interactive or
hybrid telemedicine consultation service?
Critical to the success of a telemedicine consultation service is
a staff of knowledgeable and skilled individuals who can
establish and operate the service. This group must be of
sufficient size to successfully carry out a variety of tasks
including:
The recommended method of training for all staff involved in
conducting specialist consultations via telemedicine uses the
well-known educational principle of “learning by doing”.
Relatively little new subject matter exists to master with the
exception of how the technology is operated. The primary focus
should be on learning the skills to make the consultation proceed
smoothly and effectively in accordance with the protocol that has
been approved.
What kinds of facilities are required for specialty
consultations?
Careful consideration should be given to selecting a facility.
These consultations are virtual office visits and so the many
concerns that apply to the facility for face-to-face visits also
apply to telemedicine consults. These concerns include privacy,
comfort and utility. In addition, several considerations exist
that are unique to telemedicine consults.
What kind of space is needed for the live, interactive
consultations at the remote location where the patient is seen?
At the remote site, space is required in order to conduct a
private examination of the patient. The room should be of
sufficient size to accommodate not only the patient, but also the
necessary equipment and the telemedicine presenter. Lighting is
also an important consideration. Fluorescent lighting creates
good video and the bulbs should be 3200 to 4700 degrees Kelvin.
The answer is “it depends.” Credentialing is not required when a
patient is referred by one physician to another and that patient
has an in-person encounter with the second physician. However,
the requirements for telemedicine may be different. The
requirements for physician credentialing depend on the
requirements of the facility where the patient is located and/or
the source of payment for the service.
Some form of patient consent is normally required prior to participation in a telemedicine consultation. The specifics of the consent process should be examined by the organization’s legal department. The review process may be as simple as modifying the consent to treatment form to include telemedicine consults or as complex as an entirely separate form outlining the risks and benefits of telemedicine consultations that is individually signed by the patient or his or her representative.
How do I ensure that the consultations are conducted in a
consistent, medically appropriate manner?
A good way to make sure that the consultations are conducted in a
consistent, medically appropriate manner is to use a clinical
protocol that specifies how the consultation should be conducted.
A protocol is a detailed, specific, step-by-step documented
process that describes the actions that each party involved in
the consultation should take prior to, during the course of, and
following the consultation.
A telemedicine consultation consists of a complex interaction of
people and technologies situated in different geographic
locations. The team needs to work together seamlessly in a
technology-based environment. A pilot test assembles all the
components of a telemedicine consultation into a functioning,
realistic model of the situation in which the interactions of all
the participants can be observed and improved through practice.
Once all the necessary arrangements are made, what is the
recommended process for introducing telemedicine at a remote
site?
This answer assumes that the provider site has already been set
up, the telemedicine consultation services that will be offered
have been determined, the operating protocols are in place, the
necessary business agreements have been signed, the necessary
technology has been installed connected and tested at both sites,
the remote site staff has been recruited and trained, and a local
telemedicine champion has been recruited.
The process for scheduling patients is dependent on a number of
factors including the nature of the specialty itself, the acuity
of the problem, the availability of facilities, the schedules of
the specialists involved and the systems that are used for
scheduling patients for those specialists. The purpose of
scheduling is to identify a particular time and place where a
specialist and a patient can be brought together for the purpose
of providing health care.
What typically needs to be done to prepare a patient for a live,
interactive telemedicine encounter?
Preparing a patient for a telemedicine consultation involves
several steps. These include scheduling a patient visit at the
remote site and usually registering them in the specialist’s
billing system. If the patient is new, he or she needs to have an
explanation of the nature of a telemedicine consultation and his
or her written consent to participate needs to be obtained.
What needs to be done after a consultation is completed?
The consultation process is not complete when the specialist
finishes the encounter with the patient. A number of tasks must
be completed including documentation of the encounter for
clinical and billing purposes, follow-up with the patient and/or
referring physician, protection of the privacy and
confidentiality of the patient’s medical information and helping
the patient to understand any next steps that are recommended.
Can I bill for telemedicine consultation services, and if so how?
In many instances, reimbursement for telemedicine consultations
can be equivalent to what is received for a face-to-face visit.
Medicare allows billing for a limited set of live, interactive
telemedicine services when the patient resides in a rural area,
but will not reimburse for store-and-forward consultations. Other
payors have different rules about reimbursement and different
billing requirements. The rules vary considerably by both state
and health insurance policy.
Some telemedicine issues are specific to certain facilities.
Those affected by different types of accrediting agencies (i.e.
Joint Commission) and those dependent on certain payors (i.e.
Medicare or Medicaid) have unique concerns.
How can the telemedicine consultation service be evaluated and
the quality maintained?
A telemedicine consultation is, like many other aspects of
medical care, a process that can deliver a service with a range
of quality and efficiency depending on how it is implemented and
executed. It can also improve or degrade over time as those
involved get acclimated to the process and develop either good or
bad habits.
Where do I find more telehealth operations support materials?
The Regional Telehealth Resource Centers can assist you with
identifying your operational needs, including program design and
implementation. Many of the TRCs have operational support and
materials available.
