This article covers everything you as a medical practitioner need to know about telemedicine. We will be covering how telemedicine has been affected by COVID-19, implementation guidelines, costs, technology requirements and so much more. Upvio has commissioned this article to be researched from dozens of resources internationally and to be synthesized in one place. This article is intended more as an overview rather than as prescriptive doctrine. Please ensure this information is right for your practice before implementing it.
Why Telemedicine is no substitute?
Telemedicine consultations should be conducted in accordance with existing best practice clinical standards and models of care for face-to-face consultations. While telemedicine is not designed to replace face-to-face consultations, it can be used to enhance and streamline ongoing specialist services to patients whose access might otherwise be limited. Furthermore, telemedicine is effective in alleviating congestion of hospitals and improving the utilization of medical resources and can, therefore, help reduce the total cost of the healthcare system.
The graph below (already outdated) illustrated the value of the telemedicine market pre-COVID-19. Valued at an estimated $41.4 billion dollars in 2019, telemedicine was meant to increase gradually into 2020, however due to COVID, some estimates project that telemedicine will be worth over $100 billion dollars by the end of 2020.
The product growth seen below refers to hardware and software, where service growth refers to teleconsulting, monitoring and education.
Telemedicine and COVID-19
The graphs below show how consumer, provider and government uptake and interest in telemedicine has spiked post-COVID-19:
- The uptake of telemedicine by consumers has shifted from 11% using telemedicine in 2019 to 76% of consumers being interested in telemedicine going forward.
- Healthcare providers have rapidly increased their telemedicine offering due to consumer demand and an increase in cancelled face-to-face consultation. Furthermore, 57% of providers view telemedicine more favourably than before COVID-19 and 64% are more comfortable using telemedicine.
- The type of telemedicine services offered have also expanded with more than 80 new services being temporarily approved by the Centers for Medicare & Medicaid Services (CMS).
In the past, telemedicine was primarily used to provide services such as radiology, cardiology and obstetrics.
Telemedicine has evolved significantly with platforms being increasingly secure as well as the fact that higher quality of images, sound and connectivity are provided which make virtual consultations comparable to face-to-face consultations.
Pictured above is the Ekuore remote stethescope. It allows doctors to listen remotely through an app and use different interchangeable chestpieces to avoid the risk of contagion. This is just one of many hardware innovations coming to the forefront of telemedicine.
The graph below illustrates the following:
- The use telemedicine by frontline providers and primary care physicians; with almost 60% of frontline providers and almost all PCPs utilising some form of telemedicine.
- Percentages for time spent on telemedicine: Light use (11% - 25%), Moderate use (26% - 50%), Frequent use (51% - 75%) and Heave use (76% - 100%). The majority of PCPs conduct patient care 76+% of the time whilst frontline providers conduct patient care 25% of the time or less.
Although it is evident that PCPs make use of telemedicine more frequently, the uptake of telemedicine by frontline providers are still more than 50%.
Telemedicine COVID-19 Implementation
Below are 8 essential components required for successful telemedicine integration and implementation.
To effectively and efficiently implement a telemedicine program it is crucial to provide extensive training to stakeholders, integrate with necessary platforms to facilitate video consultations and adopt new billing codes as eligibility and documentation requirements differ for telemedicine visits according to their classification.
9 Recommendations for starting to provide care via telemedicine
- Distinguish between new and established patients. New patients may be more difficult to assess due to lack of participation and trust in you as the physician, resulting in ineffective treatment of the patient. You can do this at the time of booking a telemedicine appointment. A patient appointment scheduling tool will help you do this.
- Implementation. As indicated in the graph provided above, there are a number of systems that must be implemented and integrated to successfully set up a telemedicine practice.
- Maintain privacy. Ensure the products you use are HIPAA compliant. As a medical practitioner, you are required to follow the guidelines set by the Health Insurance Portability and Accountability Act with regards to sensitive patient data protection
- Prepare your patient before their appointment. This includes chatting about whether it is in their best interest, considering the technology required by the patient and obtaining informed consent from your patient.
- Develop your web-side manner. Consider your surroundings, make sure your badge is visible and you look professional and think about possible distractions so you can eliminate them.
- Use your creativity to examine patients remotely. Some symptoms and conditions must be evaluated in person, but you can be creative in your assessments.
The Roth Score allows a preliminary assessment for shortness of breath by asking the patient to take a deep breath and count out loud to 30 whilst exhaling – potential COVID-19 patients may not be able to count to 8.
- Additional insurance needs. Consider increasing cybersecurity coverage, review business associate agreements with technology providers to understand who will be liable in case of a breach, and consider adding or increasing business interruption coverage. It is important to note that each geographical area may differ.
- Acknowledge when telemedicine is not appropriate. You should be able to tell a patient when it’s hard to fully evaluate their symptoms using telemedicine.
- Research and independently learn best practices and software. There are telmedicine webinars for medical professionals that help demistify some of the complexity.
Not all telemedicine is the same
There are three different types of telemedicine services:
- Interactive medicine: Also known as “live telemedicine”, allows healthcare providers and patients to communicate via live interactions in real time which allows for information to be shared and follow-up questions to be asked.
- Store and forward: This asynchronous method is used by first storing and then, at a later date, sending any important information (such as videos or images and diagnostic tests) to the healthcare provider. After evaluation, the healthcare provider will then provide feedback to the patient. Due to the time lag, this type of service limits the possibility of asking questions.
- Remote patient monitoring: In remote patient monitoring, patients or healthcare providers are able to enter key healthcare data such as, blood pressure levels, glucose levels or weight over an extended period of time. All this information can then be evaluated for meaningful trends or changes by a healthcare team.
The below graph indicates the proportion of regions who have reported an evaluation of a government-sponsored telemedicine programme.
Interactive telemedicine is the most common type of telemedicine, however specialities do require access to deeper, more sophisticated layers of telemedicine. In particular Teleradiology is gaining significant traction in the Americas and Europe; this method in particular relies on the 'Store and forward' method of telemedicine more than most.
10 ways telemedicine is currently being used
- Chronic Disease Management
High-tech medical devices allow healthcare providers to monitor their patients’ health over long distances. This also allows for collaboration between patients, family members and other healthcare professionals. - Sharing Medical Information
Store and forward allows providers to share information over distances. This has been a game changer as primary care physicians are able to connect with other specialists anywhere in the world. - Medication Management
Healthcare providers are now able monitor when and if their patients have taken their medication by making use of telemedicine technology. This enhances medical compliance and leads to fewer hospital readmissions. - Second Opinion
Patients are able to seek a second opinion from the comfort of their own home with the telemedicine solutions available to them. This can be done by uploading medical images and documents to the physician’s secure website. Not only is this convenient, but also saves the patient time and money as they do not have to travel far or wait long for feedback. - NICU / ICU
Webcams can be used to monitor babies from different angles. Video conferencing can also be used to allow a specialist at another location to see patients. This decreases the need for transferring patients to different hospitals or locations. - Emergency Room Diversion
ERs are the most busy, stressful and costly environments in healthcare. By allowing patients to first see a remote physician using video conferencing, overcrowded emergency rooms can be reduced. The remote physician can then determine whether a patient should seek emergency care at a hospital. - Paramedic / Ambulatory:
Through the use of telemedicine, paramedics are able to use technology to view the ER capacity in real-time instead of driving to a hospital that is already filled to capacity. - Disaster Relief:
When disaster strikes, healthcare resources are required to provide both emergent and non-emergent care which often results in a staff / resource shortage. Telemedicine allows healthcare providers in other locations to provide assistance through video conferencing. This allows for complex cases to be handled in-person vs low level cases being handled remotely. - Mobile Health:
Activities that used to happen in-person are now easily done using a smartphone. More recently, small scopes or peripherals can be plugged into a smartphone which transforms the phone into a diagnostic tool. - Device Streaming:
Certain medical devices can stream their data long distance. More detailed information about these are provided further along in this article.
Medical specialties using Telemedicine
The primary care arena has most benefited from telemedicine, but there are various other specialties that have benefited as well. The following are some examples of specialties that have benefited from telemedicine:
- Mental Health
A recent poll published in April revealed that 45% of adults indicated that the COVID-19 pandemic has had an impact on their mental health, while 19% indicated it has had a major impact.
By implementing telemedicine services, you will not only appeal to patients who prefer easy access to mental health services, but also provide increased access to patients who would not normally be able to see you regularly if they have to travel long distances. Virtual visits reassure patients that you are available and involved in their care and makes it easier for them to report early warning signs, reach out to you with questions, and make follow-up appointments to keep them on the right track.
- Radiology
Radiologists are able to receive high quality images and provide feedback from wherever they are. With telemedicine technology they are able to schedule patient appointments, allow patients to pay for services rendered and provide or request second opinions. - Pediatric
In a 2015 policy statement, the American Academy of Pediatrics declared that telemedicine has the potential to transform the practice of pediatrics. The AAP, furthermore, recommended equitable payment for telemedicine, and interstate licensure for healthcare providers offering telemedicine services.
As a starting point, look at offering behavioural health services. Other options include lactation consultations, nutritional counselling and follow-up visits to manage chronic conditions.
- Dermatology
The visual nature of assessments when it comes to skin conditions makes Dermatology a prime specialty to adopt telemedicine. Research suggests that online dermatology is efficient and appropriate, with recently published studies citing the accuracy of diagnosis rates as up to 80%.
It was found that having consultations with patients in their own homes has some advantages over face-to-face consultations at a practice as patients can show you which products they are using on their skin and can assess whether these are suitable products. Virtual visits can continue during times of lockdown where patients will not be able to visit the practice.
HIPAA - What practitioners need to know
Some definitions you need to know:
HIPAA (Health Insurance Portability and Accountability Act) is a US legislation providing security provisions to safeguard medical information. It has created guidelines that ensure information is shared securely. Although HIPAA is only applicable in the US, it is the gold standard internationally.
BAA (Business Associate Agreement) required from healthcare providers allow electronic personal health information to be stored by a third party, and covers how the third party will safeguard the data as well as resources used for continuous auditing of the data’s security. HIPAA requires that healthcare providers have BAAs with their technology provider. HIPAA doesn’t require encryption to meet compliance, but you should aim to find a provider that encrypts data.
PHI (Protected Health Information) under US law is any information about health status, provision of healthcare, or payment for healthcare that is created or collected by a Covered Entity (or a Business Associate), and can be linked to a specific individual.
Practices must follow strict guidelines in order to protect patient information and the practice’s reputation. You will require specific policies and procedures in place to properly control, disclose and protect PHI. The below provides more information on what PHI you practice can share without receiving patient consent, what special agreements are to be in place before sharing patient information as well as patient rights regarding PHI.
SaaS (Software as a Service) is a method for delivering software where the software resides on hardware controlled by the supplier. Users will access the system via a web browser or mobile application. This method puts the onus of maintenance on the supplier, and reduces the time and cost it takes to get started.
Telemonitoring is the use of video, audio and other telecommunications and electronic information sharing technologies and devices to monitor the condition of a patient remotely. It can be used to track a patient’s heart rate, activity, or blood sugar levels.
HIPAA Technology requirements
A few basic needs are required when setting up telemedicine:
- A computer or mobile device with an integrated or external microphone and camera.
- A secure broadband internet connection. The amount and speed of the connection will determine the speed of data transfer and the quality of the video.
- A video platform. There are a variety of different systems available and the choice depends on the type of system and practice you establish. It is crucial to ensure the platform is HIPAA compliant.
- Qualified computer and technical support. Support can be provided virtually or in person. Support staff will ensure stable, secure internet connectivity and must be available to assist with support queries as they occur.
Patients will require the following:
- A computer with an internet connection or an app-enabled smart phone.
Educating patients about telemedicine
Although most patients these days are familiar with telemedicine, there are still patients out there that will require some education and information. Below are some key tips to keep in mind when talking to your patients about telemedicine:
- Emphasize the benefits to your patients. Always focus on why your patient should want to do telemedicine appointments as this will remove the fear of technology and increase adoption rates. It will also increase patient participation which will lead to a more accurate assessment.
- Give your patient an opportunity to ask questions. Telemedicine could even help in this case by allowing you to ask questions during a call via chat as well as automating patient/provider reviews after calls and making use of prompting questions. Tell your patients about their rights related to patient confidentiality and privacy and how it works. Also inform them of their right to stop or refuse treatment. Another important thing to remember is to inform your patient of their responsibilities when receiving treatment.
Translators and interpreters
8% of the United States population is limited-English proficient, meaning they reported speaking English less than “very well.” As telemedicine services expand their reach, language access continues to be an important factor in providing effective care.
Qualified, professional interpreters are necessary for healthcare professionals to communicate and promote positive health outcomes for patients and telemedicine services are no different. On-demand interpretation solutions use technology to keep the telemedicine values of providing fast, affordable access to care with the highest level of accuracy in interpreting.
In addition to on-site interpretation and written translation services for healthcare providers, there are two types of interpreter services that use technology to impact telemedicine services today – audio and audiovisual:
- Video remote interpreting provides on-demand access to interpreters that can be easily integrated into a telemedicine system. Video remote interpretation, or VRI, provides the highest level of accuracy in telemedicine interpretation with the added visual support of the interpreter. In addition to access to 300+ spoken languages, VRI also allows healthcare providers to communicate with deaf and hard-of-hearing patients. A Wi-Fi tablet on a wheeled stand can be rolled to a patient, press one button on the touchscreen and choose your language.
- Audio Telemedicine Solutions: Telephonic interpretation allows telemedicine professionals to connect with patients on-demand.
Solutions like telephonic interpretation and VRI also help telemedicine to serve communities in rural areas, where on-site interpreters may be difficult to find quickly.
- Team scheduling with Upvio
Our appointment scheduling software is an ideal solution if more than one healthcare provider is required in a consultation. You are able to add multiple resources for a specific service which allows the physician and the interpreter to conduct the telemedicine consultation with the patient.
Patient consent and telemedicine
While it’s up to you to decide how much information you want to include when getting your patient’s consent, it is imperative that you ensure you meet your country’s and state’s legal requirements. If your state doesn’t have any requirements, it is still advised to follow best practices.
To see what the requirements are in your state, check out the Center for Connected Health Policy’s state map here if you are in the US.
Sample telemedicine informed consent forms can often be accessed by contacting your regional Telehealth Resource Center http://telehealthresourcecenter.org/.
Informing your patient about telemedicine
Before conducting a telemedicine consultation, physicians should ensure patients understand how the consultation will proceed. This may include:
- providing the patient with plain language information about telemedicine and also assessing whether the patient comprehends the information provided;
- informing patients of the other available care options;
- informing patients of any out-of-pocket charges for telemedicine consultations, compared to other available options;
- informing patients that one of the benefits of telemedicine is the ability to gather insurance details and payment upfront before the appointment takes place. Upvio allows for upfront payments through PayPal or Stripe to be made when the patient books their appointment online ; and
- indicating the length of the telemedicine consultation.
Physicians may need to liaise with the patient-end health worker to ensure the patient is sufficiently informed. In cases where there is no health worker at the patient end, the specialist will need to ensure that the patient has been given adequate information regarding the telemedicine consultation.
Seeking patient consent
Below are some general guidelines adopted from the FSMB’s (Federation of State Medical Boards) “Model Policy” and the American Telemedicine Association:
- Most state medical boards require that physicians are licensed in the state where the patient resides, although this may vary for each different state. It is, therefore extremely important to ensure you know the laws for the states you will be operating in.
- You are required to establish a relationship with the patient by agreeing to diagnose and treat the patient and obtaining consent from the patient to be treated by you. It is recommended that you confirm the location and identity of the patient, provide your own credentials, and disclose the treatment and communication methods to be utilized during the consultation.
- It is crucial to ensure your evaluation, consultation and all details pertaining to the prescribed treatment are thoroughly documented in the patient’s electronic health record.
- For obtaining consent from your patient ensure you comply with your state’s requirements.
- Establish an emergency plan so that you are able to refer the patient to a acute care facility if you have identified a reason for this during your telemedicine consultation.
- All medical records should be consistent with documentation and standards required for traditional healthcare.
- You must ensure that applicable federal and state legal requirements are met or exceeded for the privacy and security of medical records. This includes device security when data is being transmitted between devices.
- Measures must be put in place to guarantee patient safety when prescribing via telemedicine.
Consent
Patient consent can be given verbally, in writing, or implied by the patient’s participation or acceptance to treatment, such as holding out their arm for their blood pressure to be taken. Regardless of whether a consultation takes place virtually or face-to-face, you should be able to infer your patient’s consent based on their participation during the consultation.
There is no special consent required for offering or providing telemedicine services. That said, patients should ideally be offered the option to choose between virtual or face-to-face consultations, and should be informed of limitations linked to either choice.
However, ideally, patients should be offered the option of a face-to-face or telemedicine consult, and should be informed of any limitations for either approach.
Recording Patients
When requesting permission to record a consultation, ensure that you have a discussion with your patient prior to the consultation to ensure they have had enough time to ask the questions they deem necessary as well as consider the benefits linked to recording the session.
You will be required to provide information to your patient regarding the use, storage and management of the recording.
Gathering consent for recordings
When recording a consultation, ensure that you start the session with asking the patient whether they are happy for you to record the session. This information can then be saved and utilized if required. You can also request written consent and keep there documents on file.
Should the patient not agree to being recorded, you must inform them that you will still keep written record of the session which will be stored in the health record.
When is it appropriate to record a session?
There are many reasons where recording a consult could be appropriate. There include documenting progress, to allow you to replay the recording to another healthcare professional involved in the treatment of your patients, managing risks or for education and training purposes. Should you wish to record a session that will not be used for purposes related to the treatment of the patient, you would be required to obtain written consent from the patient.
Conducting the consultation - the workflow of telemedicine consultation
The below workflow could consist of these steps:
- Establish participant locations and the requirements of each. Some locations might already have all the required technology and equipment, but others might require these to be installed.
- Establish what hardware, software and internet connectivity will be required.
- Ensure that once the appointment is scheduled, all necessary human and physical resources are booked.
- Ensure that you confirm attendance of all required participants.
- Confirm that you have access to all necessary patient information and documentation.
- Conduct the consultation. If you are using video conferencing it is recommended that you:
- Ensure you login early to test that everything works as this will allow enough time for technical support to be requested;
- Ensure that all participants are introduced and all of them must be captured in video frame when they are talking;
- Ensure that communication etiquette is applied; and
- Ensure that you maintain patient privacy and minimize any distractions.
- Lastly, ensure that you complete the necessary documentation and add it to the patient health record.
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When there is a referring doctor
In supported consultations, a health worker from the referring healthcare organisation is present with the patient for some or all of the video consultation with the specialist. The referring health worker should confirm the identity of the patient to the specialist or health service, and confirm the identity and credentials of the distant specialist to the patient.
Have a backup plan
If urgent medical assistance is likely to be provided by telemedicine, physicians might consider installing an uninterruptible power supply and a second source of connectivity.
Can you refuse a telemedicine consultation?
The short answer is “Yes, you are able to refuse”.
What happens when you, as the physician, refuse a service if you don’t think it is clinically appropriate to be delivered via telemedicine? You will have to explain to your patient and other healthcare providers your reasons for refusal.
Telemedicine costs
By implementing telemedicine into your practice, you will start to see decreased costs as it frees up time and allows you to get insurance information prior to the consultation and can even allow patients to make payments when they book an appointment if you are offering a cash-service.
There are a few things that you need to consider though, such as, technology requirements, deciding on your rate and which conditions you are treating.
Depending on your needs and platform that will be used, initial technology costs could be higher.
When deciding on the rates you will be charging, take into account the equipment you’ll require to conduct virtual consultations. By adding a small additional fee you will quickly be able to make up your initial technology investment. Another question to ask would be why your patients are seeking out telemedicine as an option and comparing other types of medical services they could access as well as the fees charged by competitors. Lastly, also consider additional costs that patients will cut out in terms of saving on travel time as a Harvard Medical School study determined that the average doctor’s visit costs a patient $43 in lost work time.
The most important factor to take into consideration is the type of conditions you will be treating. When providing chronic care services, it might be a good idea to create subscription plans for recurring appointments. Upvio allows patients the ability to book recurring appointments once-off and a calendar entry is conveniently added to the physician and patient’s calendars for each appointment occurrence.
Advanced telemedicine
The power of AI and signal processing to monitor and measure patient vitals via a cellphone’s camera means that telemedicine and monitoring are about to progress a few steps further. Remote Patient Management / Monitoring (RPM) is a healthcare delivery method that uses the latest information technology advances to gather patient data outside of the traditional healthcare setting.
In this section we will be providing more information about remote monitoring devices, wearables and smartphone applications.
- Remote monitoring devices
Remote monitoring devices are used to measure blood glucose, blood pressure, heart rate, respiratory function to name but a few. Monitoring devices can be purchased through various suppliers, such as Ekohealth and VSee.
Digital stethoscopes, EKGs, Ultrasound, Dermascope and Pulse oximeter are examples of medical devices that can stream their data long-distance.
Due to the fact that these devices can be packed into kits and sent out into the field has proved to be useful in rural areas and developing countries where there isn’t much access to quality medical care. The use of telemedicine eliminates distance barriers and improves access to medical care that wouldn’t otherwise be available in these areas.
Wearables like FitBit also fall into this category of medical devices.
- Wearables
Wearables can be incorporated into items such as clothing. It can also be used as an accessory to capture and transmit data between a hub and source. Many patients monitor themselves on a regular basis, making these a key element in telemedicine. The data gathered can be displayed on a digital dashboard, allowing doctors to monitor patients’ vitals from anywhere.
A study by PwC found that 49% of the United States population owns a wearable device, such as fitness bands, smartwatches and glasses, smart devices and smartphones. The study indicates that the wearables market is expected to exceed $27 billion by 2022.
With the rise in chronic diseases, add to that an aging population, wearables are sure to play a crucial role in the diagnosis and management of these diseases.
- Smartphone applications
There are many telemedicine apps available that allow patients remote healthcare services from their physician from the comfort of their own home. When deciding on which telemedicine system to implement, you might want to consider whether the system caters for patients using their smartphones to access the service or whether the patient will be required to use a laptop or desktop computer.
Telemedicine in developing countries
There is a huge potential for telemedicine in developing countries as it can solve logistical constraints, provide support to weak public health systems and connect global networks of healthcare providers and workers. Ongoing issues to quality healthcare can be solved by providing cost-effective and reliable solutions. Through the development of mobile health initiatives and the creation of country-wide infrastructure to provide care in rural areas, there has been an improvement in telemedicine in these developing countries.
As mentioned previously, the majority of people today engage in telemedicine through using apps on their smartphones (also referred to as mobile health or mHealth). The World Health Organization reports that “… four in five developing nations throughout the world now offer at least one type of mobile health program to deliver essential health services to the population.”
What real doctors have to say
BY Dr Roshani Sanghani from https://aasaanhealth.com/
Telemedicinein Endocrinology and Diabetes: Challenges and Opportunities
Before the pandemic, our practice had a minority of patients every now and then over the years that had enrolled remotely in our lifestyle management programs, after hearing about us through word of mouth, and increasingly, through the internet. We considered them to be the exception, and the majority of people we worked with met us in person at regular intervals for coaching and medication changes. I believed that the time spent in the clinic should represent wellness, be enlivening and not reek of illness. So, our space was flooded with natural light, used bright energizing colors and displayed best-seller books on the shelf with an outlet to charge your phone while waiting to see the team. Aromatherapy fragrances and a peaceful soothing ambience wafted through the place in the heart of the busy city. Our team would debrief after all the patients left, discussing the teaching points and ways to improve each interaction. We laughed together every evening before heading home.
The pandemic took that away overnight. I shut my clinic to the public on March 14th, a week before Prime Minister Modi announced the world’s largest strictest national lockdown. Why? Because it seemed at the time that patients with metabolic disease, diabetes, hypertension, obesity (basically insulin resistance, exactly my patient population), were not doing as well as the others if they caught the infection. I could not justify having them sit in my waiting area, next to each other and in close proximity with my staff who rode on the crowded commuter trains to reach the clinic every day. Physical distancing became medically necessary for the safety of our patients.
These are the things I have learned about telemedicine in endocrinology and diabetes in almost six months of a 100% telemedicine practice. We transitioned overnight.
Advantages of transition to telemedicine:
1. Physical distancing during the pandemic. This needs no further explanation.
2. Existing loyal patients are glad to see you online as well. We have had old patients tell us they felt the move was seamless. Patients are actually preferring the online experience in terms of time saved. They clearly expressed that what helped them heal, was the interaction with us, and not the furniture.
3. Word of mouth still continues to bring in new patients, even through telemedicine. Many first-time patients expressed a preference to see us remotely. Doctors should start thinking of a hybrid, agile model for the future, when things start unlocking more.
4. You can deliver online patient education and engagement sessions, as an additional value-added experience to your existing patients. This outreach helps them feel connected and supported.
5. Frustration in the waiting room disappears. Every clinician knows that a busy clinic faces the pressure of moving quickly, and every extra few minutes spent with the one patient who breaks down in tears and needs your comforting presence, is snowballing the number of people becoming frustrated at the increasing wait to see you. With telemedicine, the receptionist is able to message the next few patients and inform them in case of the odd delays, with less disruption or wastage of time for the patient. Of course, if a patient has a packed schedule with back to back work-from-home meetings and calls, these patients should be given the first slot of the day, just like we used to do with physical appointments. There will always be people who genuinely need to get in and get out exactly on time (more than the doctor would like to admit), without brutal delay and loss of working hours sitting unproductively at the doctor’s clinic. I am one of those myself and most doctors would consider themselves in that category. All you need to do is sit with your scheduling team and identify which patients need priority for the first slot of the day, (or the last slot of the day if you know they really just need the extra time to talk without a gun against your head).
6. In a city like Mumbai, telemedicine saves the time spent in traffic/monsoon floods to reach the clinic. In a world where time is money, this should be given importance in the future.
7. As physical distancing norms will remain for the future, Indian outpatient departments will not be able to continue large walk-in clinics where people crowd without an appointment and waiting to be seen on a first come first serve basis. Pre-booking appointments with online payment will reduce long lines and space appointments out. Payments are seamless and there are less cancelled appointments or “no-shows”. This advance increases efficiency of scheduling, billing and documentation. In a country like India, the majority of clinic visits are self-pay. Often the doctor is not sure if the patient will actually turn up, until they walk through the door.
8. Clinics are forced to improve digital recordkeeping. In India, the entire medical history would often be in a thick file in a plastic bag the patient carried around. On a lighter note, I remember having to request my nurse to have patients take the records out of the plastic wrap before the consultation to avoid the loud crinkling noise of plastic! Telemedicine is forcing digitization and therefore portability of health data.
9. Continuous glucose monitoring devices allow for remote assessment of patients’ diabetes with fewer glucometer pricks. For example, Abbott has a third party vendor for ambulatory glucose profiling devices to be applied at the patients’ location, which can be uploaded and sent electronically to the doctor after 14 days for interpretation and consultation.
10. Weekly interactions for behavior coaching and lifestyle counselling are a big part of a comprehensive diabetes or endocrinology practice. These are very amenable to deliver online via voice or video. These do not require a full physical examination each time.
11. Prescription changes sent and documented online are time-saving for the doctor and patient.
Disadvantages/ Cautions
1. A global learning curve means we need additional vigilance in the area of data privacy and protection of personal information. In India, reports are being sent across Whatsapp, Google drive, Telegram, Zoom and email. This needs large scale training and education both at the level of patient and provider.
2. Physical examinations necessary for a complete medical evaluation cannot be done online. For example, a new patient seeing us online for diabetes had fallen at home two days before the virtual appointment and displayed asymmetry of her smile. I felt the left corner of her face was drooping slightly when she smiled. It was so subtle that nobody had really noticed it although she reported vague weakness over the last few months. I suspected a mild old stroke, but had no way to make such a diagnosis online. Only when a physical therapist paid a home visit to assess her fall risk, did we realize that she had all the examination findings of an old but mild left sided stroke, and other skin changes that had been missed on the virtual consultation.
3. Specific endocrine and diabetes examination features such as edema (fluid overload), decreased sensation (neuropathy), feeble pulses in the feet (impaired circulation), detailed exam of non-healing diabetic wounds/ulcers, feeling thyroid nodules or goiters, standardized measurement of exophthalmos in Graves’, assessing proximal muscle weakness, checking tendon reflexes cannot be done via an LED screen. With remote stethoscopes, one can listen for abnormal sounds (bruit) over the thyroid or in the neck, however these are not widely available.
4. “Bedside manner” referred to how doctors conducted their relationship with their ailing patient. There is reason why couples who live in different cities are described as being in a “long-distance” relationship. The doctor-patient relationship is of course, very different than an intimate personal one, but humans have always enjoyed face to face interaction as the default for interactions that mattered. Not all patients or doctors are comfortable managing vulnerability on a screen. Sometimes all one needs is a pat on the back, a hand placed on the shoulder, or a hug.
5. There is a steep learning curve and more senior doctors with excellent clinical skills may feel lost or disconnected as the younger doctors innately switch to digital interactions as something that is native to them. There needs to be rapid training done to keep the vast skillset of experienced clinicians available to their patients as the world continues to face this pandemic. After all, medicine is an art as well as a science. There is a reason it is referred to as “practice”.
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Consider the following software
Upvio.com - your HIPAA compliant patient scheduler
- Ask your own questions – Gather information about your customers as they are booking with you. Ask the important questions and manage expectations.
- Email & SMS reminder – Create custom email and SMS notifications and reminders to reduce no-shows.
- Multiple staff, businesses & locations – Each business can have different staff, services, appointments and customers
- Google Meet, Zoom & Doxy.me – Generate unique meeting links or use a protected virtual meeting room.
- Zapier, Webhooks & API – Integrate your system with Upvio, exchange information & create custom integrations.
- PayPal & Stripe payments – Enable payments from your customers before appointments are scheduled.
- All begins with a calendar – Works with your Google or Outlook 365 calendar. Embeds directly into your website.
- More awesome features – Set buffers between appointments, translate into your language, create recurring services, create group booking services, accept payment and set reminders to your customers.
- Control your availability – automatic time-zone detection
On average a Upvio form takes 50 seconds to fill out! Imagine how easy that's going to be for your customers.
Doxy.me – Your simple, free and secure Telemedicine solution
Doxy.me makes telemedicine simple and easy for you. Create your personal room and start practicing telemedicine today.
By keeping it simple, Doxy.me makes it easy for you to get started:
- No download required – With accessibility in mind, we have made Doxy.me extremely simple and easy to use for both clinicians and patients.
- Free to use – We believe cost shouldn’t be a barrier to telemedicine. That’s why Doxy.me is free for all.
- Worldwide usage – HIPAA, GDPR, PHIPA/PIPEDA, & HITECH compliant: We meet worldwide security requirements.
- BAA included – All individual providers get a free Business Associate Agreement (BAA) with Doxy.me. Sign up for free to download your BAA.
- Accessible from anywhere – You can access Doxy.me using your desktop, tablet and smartphone.
- Live chat – With live chat you can simply and easily communicate with a patient by text, even while you are on a call with a different patient. Live chat is also a great compliment to audio and video.
- Patient queue – You’re a busy provider and sometimes run late. The patient queue allows you to see that your next patient has checked in, and even allows you to jump between patients quickly and easily.
- Patient check in – We believe the patient experience with Doxy.me should be just as amazing as yours. The patient check in process is the first impression that patients experience with Doxy.me.
- Quality video – Doxy.me features high quality HD video and audio to ensure you and your patient have the best experience possible.
- Waiting Room – Personalize your waiting room with text, pictures, and videos for your patients to enjoy while waiting for you.
- Meeting History – With Meeting History, Doxy.me will automatically keep track of the date, time, and duration of every session so you don’t have to.
By incorporating standard clinical workflows such as patient check-in and waiting room into the design of Doxy.me, healthcare providers and their patients experience a familiar and natural visit.
We’re changing telemedicine. So you can change the world!
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