Telehealth Operations Module
Developed by: The Great Plains Telehealth Resource and Assistance Center under a HRSA Office for the Advancement of Telehealth grant

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 »

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Types of Telemedicine Specialty Consultation Services

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.

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Organization of Telemedicine Services

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.

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Getting Started

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.

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Staffing and Recruiting Specialists

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:

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How should staff be trained to use telemedicine?

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.

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Facilities at the Provider Site

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.

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Facilities at the Patient Site

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.

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Credentialing and Licensing

Do provider/specialists have to be credentialed?

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.

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Legal Issues (Privacy and Contracting for Services)

Is patient consent required?

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.

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Creating Protocols

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.

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Pilot Testing

Why is it important to do pilot testing?

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.

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Introducing Telemedicine Services to the Community

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.

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How are patients and clinics scheduled?

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.

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Patient Preparation

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.

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After the Visit

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.

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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.

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Issues specific to Certain Types of Health Organizations

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.

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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.

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More Information

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.