In this article, Robert A. Dowling, MD, covers some practical aspects of telemedicine and what it might mean for urology.
Dr. DowlingTechnology is changing the way health care services are delivered, and has introduced at least two new terms into the medical professional’s lexicon: telemedicine and telehealth. Once considered separate concepts, telemedicine and telehealth are now used interchangeably to refer to what the American Telemedicine Association (ATA) defines as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.”
As examples of telemedicine and telehealth, the ATA lists “patient consultations via video conferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education, consumer-focused wireless applications and nursing call centers, among other applications.” Teleradiology, remote intensive care unit monitoring, and remote retinal imaging are all early forms of telemedicine. In the 2015 final rule, the Centers for Medicare & Medicaid Services announced some changes to expand reimbursement for telemedicine and by doing so signaled that this has gained official status in the eyes of the nation’s largest payer.
In this article, I will cover some practical aspects of telemedicine and what it might mean for our specialty.
Why consider telemedicine for urologists? According to the American Health Information Management Association, telemedicine offers benefits to patients and providers, including reduced costs, improved access to physicians and services, improved continuity of care, and even the potential for reduced travel costs and time off work. One potential application of telemedicine that may illustrate these benefits is the urologic care of patients in a skilled nursing facility. Many of us have seen our staff, our patients, their families, and the staff of transport services needlessly burdened by an issue that could have been handled remotely by telemedicine-conferencing with the caregivers at the facility.
Telemedicine may be practiced in at least two broad categories. Asynchronous telemedicine refers to email, store and forward, or other similar types of movement of medical information from one site to another. In our specialty, a relevant example might involve receiving a computed tomography image or a photo of a genital lesion for expert opinion. Obtaining CME hours via a downloadable course is another example of asynchronous telehealth services.
Synchronous telemedicine involves the use of dedicated hardware for two-way communication among providers, patients, and other professionals using tools such as videoconferencing applications (Skype, GoToMeeting, Zoom, and others). Robotic surgery within or between buildings is a form of telemedicine.
Remember that regardless of the mode, the transmission of protected health information will be governed by HIPAA privacy and security rules and you should ensure the appropriate “reasonable” precautions have been taken to minimize the risk of a breach or violation. Consult your attorney and compliance professionals.
Next: Take note of licensure, standards
Another very important concept in telemedicine is that of licensure and standards. While some precedents have been set with the widespread adoption of teleradiology, states vary widely in their approach to credentialing and licensing the practice of telemedicine. Some states require an unrestricted medical license to practice telemedicine in the state; others have created special restricted telemedicine licenses; and still others require no license if the telepractitioner is only providing interpretative services. Check with your state medical board if you intend to engage in telemedicine that crosses state lines, and for other rules and regulations related to telemedicine in your own state.
The ATA has also issued a white paper on this subject with detailed information by state. Finally, the ATA has a rich set of practice guidelines, information about malpractice insurance, and other helpful resources for those contemplating the adoption of telemedicine.
CMS telehealth coverage policies are readily available online and describe eligible providers, sites, beneficiaries, and covered services. The location of the beneficiary (patient) is referred to as the “originating” or spoke site, and in order to be eligible for telehealth, the originating site must be in a designated rural health professional shortage area (which can be determined with a tool available online at www.hrsa.gov/shortage/). Qualifying originating sites include the offices of physicians or practitioners, hospitals, skilled nursing facilities, rural health clinics, and others. The location of the provider performing telemedicine is referred to as the “distant” or hub site, and Medicare only covers synchronous telemedicine services.
The list of covered services for 2015 Medicare beneficiaries includes new and established office visits, subsequent hospital and nursing facility care visits, inpatient teleconsults and follow-ups, and others, and can be viewed on CMS’ website. Medicaid policies vary by state, and in some cases may be more liberal than traditional Medicare. The provider at the distant site bills for one of the covered professional services with a telehealth modifier GT, and the facility where the patient is located-the originating site-bills a facility fee HCPCS code Q3014.
Let’s take an example: A primary care physician hospitalizes a patient with urosepsis in a qualifying health professional shortage area and requests a consultation from you, the urologist. Using certified two-way visual conferencing technology and the assistance of a telepresenter at the originating site, you interview the patient from the computer in your office, review the pertinent records, observe a delegated physical exam, and recommend a CT scan without contrast to assess the upper tracts. You would submit a bill for the professional consultative service (HCPCS G0426, for example) and the rural hospital would bill the facility fee as described above.
Bottom line: The confluence of technology, a shortage of physicians in certain parts of the country, a work force issue in our specialty, and a willingness of some insurance companies to step outside traditional reimbursement policies has created a potential tipping point for the increased adoption of telemedicine in specialty care-including urology. Urologists should be familiar with these trends and explore the role of tele-urology in their own practice to achieve some of the potential benefits.
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