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​Implementing Telemedicine in 2020: Don’t Fall Behind the (COVID-19) Curve

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If you are like many healthcare providers, your methodical plans to introduce telemedicine in the next few years has suddenly been accelerated and upended by the COVID-19 pandemic. Some providers suddenly need to see ten times more patients remotely, if not all their patients. What is the best way to deal with such a radical disruption?

Telemedicine was already a growing trend before 2020, with tech-savvy patients expecting increased flexibility, and healthcare providers looking for modern solutions to increase the efficiency of their practices. When the pandemic hit, both patients and practitioners were forced to stay home in order to flatten the curve, so telemedicine became even more important—and sometimes mandatory. It is not temporary, however. Any work you put into a telemedicine plan today will have long-term consequences, because telemedicine is here to stay.

Whether you have dabbled in telemedicine before or the urgent need is entirely new, it is crucial to consider all the benefits, risks, and practical steps that you need to take in order to serve patients at home. This article will walk through a process for getting started quickly.


Telemedicine is Real Medicine

In 2018, almost one out of every four patients had a virtual visit with a doctor or nurse, and out of those who had not, more than half would be willing to give it a try (Deloitte Survey of US Physicians, 2018). The majority of physicians are also willing to try telemedicine, though many have not moved forward with it yet, perhaps due to technological barriers to adoption, or the lack of an urgent need until now. An exception is psychiatrists, of whom the vast majority are both willing and able to transition to telemedicine (American Well, 2019).

With adoption of telemedicine becoming widespread, it is also becoming clear that it may be as effective as traditional medicine in the right circumstances. For example, one before-and-after analysis of a behavioural health program delivered via telehealth demonstrated wider reach, high patient satisfaction, and significant reductions in symptoms of depression, anxiety, and stress (Dent et al., 2018).


COVID-19 Has Boosted Adoption of Telemedicine

Telemedicine was traditionally used to reach remote or rural patients, but with improving telecommunications technology, and now COVID-19, the use case for telemedicine has expanded, likely permanently.

Many providers will not be able to transition entirely to telemedicine overnight, especially if treatment requires physical contact or specialized equipment. However, portions of the process may be easily conducted remotely, such as intake interviews, check-ins, and follow-up assessments. Telemedicine is not an all-or-nothing proposition; consider which parts of your practice can most easily be transitioned, then introduce telemedicine where it is viable and valuable.

As you make this transition, perhaps at an accelerated pace, it is important to consider present and future challenges that may come up. Develop a plan that captures advantages and anticipates challenges, implement the first version of your plan, then iterate as the situation changes.

The rest of this guide will quickly review the main areas to consider when developing a telemedicine plan, with a particular emphasis on mental health care and the remote assessments that Cambridge Brain Sciences specializes in.


Why Implement Telemedicine? The Benefits of Remote Care

Why is telemedicine on the rise and here to stay? In short, providers are realizing that telemedicine results in benefits that have nothing to do with the short-term pressure from the pandemic. Start to shape your telemedicine strategic plan by identifying the main goals you are aiming to achieve.


Better Patient Care

The days of viewing telemedicine as a compromise are over.

Studies have found that telemedicine results in fewer admissions, better patient outcomes, no impediments to the doctor-patient relationship, no decrease in safety, and no decrease in patient satisfaction. Again, it is not all or nothing—parts of the patient flow may be perfect for telemedicine, improving the overall efficacy of the process. Many practitioners ease the transition from in-person care to everyday life via follow-ups that are actually better delivered via telemedicine, for example. With the low cost of telemedicine (see below), it is possible for follow-ups to be more frequent, or kept up for longer, which can ease patients into integrating the treatment in their everyday lives and ensure treatments have a long-term effect on patient health.

Remote patient monitoring is one key focus for many healthcare providers looking to improve patient care. Devices and software that remotely collect and send data to a healthcare provider can be used to adjust and enhance in-person treatments, and monitor for potential issues when a healthcare provider is not nearby. CBS Health is an example of a digital product that can easily monitor a patient’s brain health from a distance.


Serving Additional Patient Populations

Rural areas have historically been a target for telemedicine, but the concept of reaching additional patients who would not normally seek in-person treatment extends beyond remote locations. COVID-19 has emphasized the need to reach patients at home, but for many patients, the need already existed, and will continue to exist after lockdowns have lifted.

Patients with physical or mental disabilities that make travel difficult may be reachable with virtual care. A wider range of symptoms may also be treatable by providers who have implemented telemedicine. For example, patients with milder symptoms, or who would benefit from long-term preventative programs, may not have considered traditional treatment, but may reach out for a telemedicine consultation that requires less effort.

Additional services only deliverable by telemedicine can also reach new patients specifically seeking those services—see below for more on new services and revenue opportunities.


Reduced Costs

Many healthcare providers find that telemedicine reduces costs, especially long-term. There may be capital costs, such as new technology infrastructure, equipment, and training, but these often pay for themselves quickly in a well-managed telemedicine plan. In one recent survey, 69% of organizations surveyed realized cost savings from telemedicine services, and 29% of them generated savings of 20% or more.

Sources of reduced cost include fewer cancellations and readmissions, less of a need for expansion of physical space, and reduced need to hire new staff, even as the patient roster grows.

These cost savings for healthcare providers do not come at the expense of patients. Travel costs, parking, and even taking time off work can be major costs associated with travelling to an in-person visit, and may even prevent some patients from seeking treatment.


Less Administrative Burden and Easier Scheduling

In addition to raw financial savings, telemedicine has potential to save physicians and patients time. By overcoming barriers associated with time and distance, a healthcare clinic’s resources can be used more efficiently.

Technology can replace tasks that would typically take up administrative time with self-service processes or automation. For example, a self-service online scheduling portal can ensure that appointments are easily initiated, modified, and tracked, with little need for manually juggling appointments (e.g., see OnCall). Remote follow-up assessments can also be automated—for example, CBS Health can put patients on a series of scheduled assessments with only a few clicks from a practitioner or admin staff.

A hidden advantage of digital over physical, and deeper integration with technology in general, is that fewer mistakes are introduced by transcription errors, verbal misunderstandings, and other issues due to human error. With more automation and fewer faults to correct, the result is a more efficient practice overall.


Increased Revenue and Additional Services

Seeing more patients for the same or lower costs is enough financial incentive to consider telemedicine, but there is also potential for entirely new streams of revenue.

First, note that reimbursement for existing services is usually not a source of increased revenue for practices moving forward with telemedicine—rather, increases in new or retained patient volume tend to lead to financial benefits. New services that reach additional patients, or better serve existing patients, are one way to accomplish that.

Following up post-treatment is a potentially fruitful area to introduce new services. For example, sending automated cognitive assessments after a patient has been treated for depression can help demonstrate the efficacy of the treatment in the short term. Long term, the patient will keep your practice in mind, and the assessments will monitor for any signs of relapse that may require additional treatment, when appropriate. Some practitioners have introduced subscriptions, service bundles, or a concierge health model in order to keep in touch with patients on a regular basis, and telemedicine can help keep such a service from being too costly to maintain.



With telemedicine, patients can technically be almost anywhere.


Avoiding Telemedicine Challenges

All these benefits sound great, right? But it is not all sunshine and rainbows—there are reasons that some practitioners avoid telemedicine, aside from the healthcare habit of sticking with the status quo. Government and public health agencies are quickly easing restrictions to make the transition to telehealth less cumbersome, but there are still real and perceived barriers that can make implementing telemedicine a challenge. Consider possible challenges that may come up, and develop a plan that acknowledges them.


Navigating a Complex Billing Landscape

Receiving reimbursement for services provided remotely has been one barrier to implementing telemedicine for many practitioners. Billing can be a complex endeavour, with uncertainty about which codes to use and whether or not claims will be approved. The specifics vary by country and by state. Always check with your local payer before implementing your telemedicine plan, so that you can ensure your processes are designed to be eligible for reimbursement, and you can properly plan the return on your investment by outlining which services will lead to revenue and which will be a cost to absorb.


Meeting Licensing, Medical Board, Compliance, and Insurance Requirements

Depending on your profession, there may be a licensing body or medical board with its own requirements. Licensing is often state-specific, which makes treating patients in another state problematic, even if performed via telemedicine. COVID-19 has caused restrictions to be loosened, but consider your long-term telemedicine plan—will you want to build a long-term relationship with a patient in another state if it has to end after restrictions have been lifted? The same types of challenges come up when considering compliance with your state’s or country’s healthcare regulations and legislation. When building your plan, setting limits can be critical, especially when it comes to meeting the various requirements required in your profession.


Developing a Telemedicine Strategic Plan

If you are sold on the benefits and willing to navigate some of the complexities, then the next question is: where do you begin? Use this five-step guide to a strategic plan as a starting point, and be sure to follow relevant links to more detailed information to flesh out your plan and maximize your chances for success.


1. Determine Compliance Requirements

There are three main areas to consider under the category of compliance: licensing, insurance, and legal requirements.

  • Licensing. Licensing requirements may be temporarily loosened, but always check with your profession’s local licensing body (see also: list of states modifying requirements for telehealth in response to COVID-19). Be sure to determine whether you can reach only existing patients with telemedicine, or if you can start a new relationship with a patient remotely. Your state’s medical board, for example, will have more information about which types of patients will be affected by your telemedicine plan.
  • Insurance. Talk to your insurance broker to make sure they are aware you are going to be seeing patients via telemedicine, especially if you will see patients in other states. You may be subject to liability laws of the patient’s state, which may affect insurance rates. Telemedicine-specific insurance may also be a requirement—for example, some insurance companies provide protection in the unlikely event of a cyber attack. Every situation is different, so talk to your broker to make sure your insurance is still doing its job. The conversation with your broker may affect other aspects of your strategic plan, such as the locations from which you will accept patients.
  • Legal. Become familiar with applicable federal and state laws that are relevant to your plan. All countries and states have laws concerning delivery of healthcare and handling of personal information. Again, restrictions may be lifted due to COVID-19, so consider your timeline. The American Telemedicine Association provides resources about local policies for United-States-based practitioners, including a list of state laws and reimbursement policies.


Collect this information about compliance first, so that the following steps in developing your plan can be properly laid out, and work within limitations so your plan is not so ambitious as to run into compliance issues once you get started.



Consumer technology can play a large role in telemedicine.


2. Update Technology Infrastructure

Modern telemedicine often focuses on synchronous communication—that is, real-time two-way communication. However, consider the technology needed for asynchronous communication as well, which allows you and your patients to respond when it is most convenient, and may make for more efficient use of time. Capabilities like the scheduling feature of CBS Health automate communications on your side, while allowing patients flexibility to determine when to perform assessments, within a reasonable window.

Fortunately, an initial telemedicine plan can often be implemented using existing consumer technology, such as laptops, which often have integrated webcams and microphones, and can run any software required. Test existing equipment first to determine if it is up for the job. Pay attention to the quality of the screen, the speakers, and the microphone. Deficits may be overcome with an external webcam or a headset for voice communication.

Many tools are web-based, such as CBS Health, or have a web-based option, like most videoconferencing platforms (e.g., Doxy.me). Using web-based services can further simplify treatment, for both practitioners and patients, as no new hardware is needed, and no software needs to be installed. Online platforms also update automatically, so that improvements or changes affecting compliance can be taken care of by the vendor, with little or no action needed by the practitioner.

Flexible web-based technology is also better able to integrate the devices already present in patients’ lives. Most patients today have a computer, tablet, or smartphone available for videoconferencing or remote assessments. Additional health technology may already be present in patients’ everyday lives as well. According to Deloitte, the majority of consumers are willing to share information collected via wearables, digital scales, and other home technologies with their doctor.


3. Update Protocols, Policies, and Communications

A telemedicine plan will require updates to the protocols, policies, and communication materials that make up the everyday flow of your practice.


Update Protocols and Processes

Examine the patient journey, from intake to treatment to long-term follow-ups, and determine which parts of the workflow can be improved by telemedicine. Remember to consider areas such as:

  • Intake process. Update your intake process to involve discussions about telemedicine. A treatment plan for an individual patient may or may not involve remote care, depending on their individual needs, abilities, and preferences. Some patients may require specialized equipment or deficits that require a helper to operate a computer, in which case telemedicine may not be appropriate. An initial interview with a referring provider may further reveal which patients are good candidates for telemedicine.
  • Treatment plans. Any treatment flow involving telemedicine will need modification. New treatment plans may include continuity of care components, such as maintaining a relationship with the patient from a distance, and sharing information with other healthcare providers. Conversations with patients about their treatment plans should include a roadmap for what happens after physical distancing restrictions are lifted and telemedicine is only one of several options.
  • Safety plans. Not being physically present with a patient does not absolve any practitioner of the need to consider safety. Policies may need to be updated to include local resources, such as instructions about who to contact in an emergency situation in which a local presence is needed. For some patients, telemedicine may pose a safety risk—such as when living with an abusive partner—and the protocol for determining whether or not telemedicine is appropriate should prevent such possibilities as much as possible.
  • Physical space. You may need to modify or rearrange your space in order to provide an area with good lighting, fast WiFi, and separation from other rooms. A separate physical space is important for providing both noise isolation and privacy, and applies to both ends of a videoconference.
  • Staffing and training. Prepare the care team for the changes brought on by introducing telemedicine. Your plan may necessitate updates to roles and responsibilities—for example, tasks previously carried out by a physician may be transferred to staff if there is a high degree of automation involved. However, watch out for any role restrictions put in place by reimbursement policies, or concerning compliance. When introducing new technologies, check with vendors to see if training is offered—usually itself delivered via teleconference!
  • Technology support. You may not be accustomed to having IT support on-hand, but a side effect of greater reliance on technology is a need to troubleshoot patient tech woes. Have a process for when a patient gets into trouble with technology, such as defining who is responsible for helping them, and a bank of responses for common issues.
  • Documentation. Build documentation into your plan. Being farther from patients does not lessen the need to keep complete and accurate records. This is not merely because of a philosophical need to emphasize that remote patients are equal to those seen in-person, but a practical concern too, in the case of any legal disputes that may arise, and to ensure that other healthcare providers have access to all relevant information about the patient.


Update Communications

The materials you use to communicate with patients and prospective patients will need to be updated to include telemedicine. Examples include:

  • Forms. Informed consent documents may need different versions for telemedicine appointments and in-person appointments. The form should specify what process patients will go through, and which steps will be carried out remotely. States will vary in the requirements for the contents of each form, but the Federation of State Medical Boards has a model policy for appropriate use of telemedicine to start with.
  • Marketing materials. Your website should be updated to include telemedicine materials, especially if you hope to reach new patients who are interested in your services. Post notices about the switch to telemedicine, and mention these updates on social media as well. Especially in the wake of COVID-19, many patients will be wondering about your telemedicine policies, so make this information prominent. Consider updating your search engine optimization (SEO) strategy as well, to reach prospective patients searching for services you offer.
  • Scripts, emails, and brochures. Patients need to be aware of the differences between telemedicine and the treatments they may be accustomed to. These differences can be communicated via scripts delivered by phone or videoconference, emails, or brochures picked up in person or mailed. Be sure to also outline requirements for participating in telemedicine, such as device specifications and visual or motor skills needed. An example of an introductory document is the CBS Health Overview for Patients, which provides a quick introduction to remote cognitive assessments.


Other written materials to update may include emergency and safety procedures, training documents, job descriptions, and reimbursement procedures. We will cover reimbursement in more detail next.


4. Develop a Reimbursement Plan

Receiving reimbursement from insurance and other assistance programs is a complex area that has a large effect on the financial situation of a health practice. Your telemedicine plan should include steps to determine the effect on reimbursement. Adjust your implementation to continue receiving reimbursement wherever possible, or integrate additional procedures that are eligible for reimbursement.

Luckily, the billing situation for telemedicine is improving rapidly. As of 2017, 48 state Medicaid programs provided reimbursement for synchronous telehealth services (source), and COVID-19 has jumpstarted federal and state guidelines to ease restrictions on what can be considered telemedicine. For example, some services that could previously only be delivered to remote rural locations can now be delivered to patients in any location, often at the same rate as an in-person visit.

Navigating reimbursement can still be quite complex, however. The Center for Connected Health Policy maintains a list of current state laws and reimbursement policies related to telemedicine, and Aetna has an updated list of approved behavioural health telemedicine services, including relevant codes. Check with telehealth vendors for additional guidance. CBS Health provides a reimbursement guide for cognitive assessments, and we have outlined the expanded telehealth benefits due to COVID-19 in the U.S.


5. Set a Timeline, Measure, and Iterate

With the main areas of your telemedicine plan thought out, it’s time to set a schedule. Some key recommendations to consider when setting a timeline for your telemedicine rollout include:

  • Designate a point person. The entire plan will go more smoothly if you can identify a point person who is enthusiastic about making the telemedicine plan work, can keep it on schedule, and is available to guide staff through any changes.
  • Consider a pilot. A small implementation with a limited number of patients who are most easily transitioned to telemedicine can help work out any kinks before a wider implementation.
  • Set a timeline. When is your start date? Will you introduce additional services over time? Are any parts of your plan temporary (e.g., reverting to traditional in-person services as soon as COVID-19 restrictions are lifted)? Set a timeline, but always treat it as a flexible roadmap. Temporary plans may demonstrate that telemedicine has a wealth of benefits that are worth continuing with long term.
  • Incorporate program evaluation. The success of your plan should be demonstrable with metrics and other evidence of efficacy. Set goals for your plan, then collect metrics to ensure they have been met. Goals do not always need to be ambitious—especially in the current emergency conditions, the overall goal may be as simple as continuing to practice without affecting costs or patient satisfaction. Evaluated data may include patient satisfaction, business metrics (cost savings and revenue vs. setup and maintenance costs), and clinical outcomes like the brain health measures provided by CBS Health reports (see Shore et al. (2014) for a more complete lexicon of outcome measures for telemental health).
  • Iterate. Based on evaluation of your initial implementation, identify strengths and weaknesses, then iterate. The next version of the plan may include more services, new technologies, or clearer processes. Telemedicine is here to stay, and organizations that continue to iterate and innovate will thrive in this new normal.


Conclusions

There will be no going back when it comes to telemedicine. The widespread adoption of virtual healthcare will surely stick around long past 2020, and continue to grow. Your workflow will need to adapt as the healthcare landscape changes. Based on the success of your initial telemedicine strategic plan, consider how it can be improved and expanded upon to continue maintaining and improving the health of your patients.


Additional Resources


Disclaimers: this guide is for informational purposes only. Cambridge Brain Sciences is not providing medical, legal, or financial advice, and this guide is not a substitute for the advice of a physician, attorney, or other financial or consulting professional. Reimbursement-related information provided here is for guidance purposes only—Cambridge Brain Sciences can not determine your eligibility for reimbursement and does not assume responsibility over the outcome of any claims. Please contact your local payer to determine whether you qualify for reimbursement, and if any coding and coverage guidelines exist.


Stock images provided by Pexels.com.

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