Integration of telemedicine into clinical gastroenterology and hepatology practice
Telehealth and teleconsultation
Advancements in telemedicine have outpaced the ability of legislators and institutional officials to provide oversight on legal and regulatory issues. Each state sets requirements for providers to engage in telehealth activities. The ATA published the State Telemedicine Gap Analysis to address specific requirements and limitations for each state.19 Issues addressed in this document include the requirement for a face-to-face visit before a telehealth visit, informed consent, and interstate practice. Virtually all states have barriers to providing telemedicine services unless the provider is licensed in the state where the patient resides. To promote telemedicine, the Federation of State Medical Boards proposed the development of an Interstate Licensure Compact in which 17 states participate (AL, AZ, CO, ID, IL, IA, KS, MN, MS, MT, NV, NH, SD, UT, WV, WI, and WY).20 Two key principles include defining the practice of medicine as the location in which the patient resides and placing the provider under the jurisdiction of the state in which the practice occurs. The TELE-MED Act of 2015 has proposed allowing Medicare physicians to provide telehealth services to patients regardless of the state in which they reside.21 In regard to liability, the number of malpractice cases involving telemedicine services is low; most are related to e-prescribing, as opposed to care provided during teleconsultation services.22
However, some unique liability issues relative to telehealth encounters exist. First, when considering standard of care, what do you compare a telemedicine encounter with? Hardware or software malfunctions can occur, with a subsequent inability to provide the telemedicine service. Loss of protected health information through hackers or equipment failure is another potential threat. Reimbursement for telehealth services is also regulated by states and is subject to wide variability; 29 states have laws in place requiring private payers to reimburse for telehealth services at the same level as an in-person encounter.19 The ATA recently published an analysis of issues related to reimbursements.23 In addition to parity, key issues that must be addressed include the failure of the majority of state health plans to provide coverage for telehealth services to employees, restrictions on providing telehealth in nonrural settings, restrictions that are based on the type of health care provider, and restrictions on home monitoring.
The Mayo Clinic, Rochester, Minn., offers outreach to its health system affiliates via a secure video conferencing platform to allow face-to-face consultations for patients with IBD. Consultative appointments are scheduled during preassigned blocks of outreach time on the clinician’s calendar. A nurse transcribes any recommendation that requires an order from the referring gastroenterologist. Health care providers offering video consultation are required to have a medical license for the state in which the patient resides and to be credentialed by the facility to which the Mayo Clinic provides services and the payer reimbursing for the service. The majority of consultations are for discussions regarding medical management: when to start a biologic, safety concerns, monitoring strategies, or for a second opinion regarding the need for surgery for refractory UC or fibrostenotic Crohn’s disease. Access to imaging and laboratory work is facilitated through previsit evaluation performed by a nurse in the referring practice.
If services are provided via consultation to a patient at a non–Mayo Clinic facility via the Affiliated Care Network, there is a legal contract outlining reimbursement as well as terms and conditions. For asynchronous consultation where there is interaction with a provider but the patient is not directly involved (no face-to-face consultation), the practice of medicine regulations vary from state to state as outlined above. Credentialing is not required for provider-to-provider consultation at each site but sometimes a license is. However, for all states, electronic health record documentation of the clinical question and recommendations is important. Substantial administrative infrastructure is required to manage the quality of e-consult responses so that they are timely and the clinical notes meet the needs of the requesting provider. This is supported by a secure online portal that exchanges electronic health record information and the clinical note generated. Mayo Clinic providers are licensed for multiple states to provide medical consultations to various affiliated hospitals throughout the United States. The consulting physician always has the option to recommend a full face-to-face consultation if review of the records provided indicates the patient appears to be too complicated. The telehealth efforts at the Mayo Clinic are not isolated to gastroenterology; it is estimated that, through expanded use of telehealth, Mayo Clinic will provide care nationally and internationally for 200 million people by 2020.24
From April 2015 to May 2016, at the University of Maryland, Baltimore, we conducted 89 telehealth visits. According to state regulations and payer restrictions on reimbursement, patients were eligible to undergo telehealth visits if they had a prior face-to-face visit and were insured by Blue Cross Blue Shield. Eligible patients provided informed consent to participate in the telehealth visit. Patients received an email with instructions on how to download the required software (VidyoDesktop version 3.0.4[001]; Vidyo, Hackensack, N.J.) onto the patient’s home computer, tablet, or smartphone. An office assistant conducted a test visit to make sure that the connection was adequate. Eighty-three percent of patients reported that using the system was not complicated at all or only slightly complicated. Seventy-one percent reported that the telehealth visit took significantly less or less time than a routine encounter; 88% said that all their concerns were addressed during the telehealth visit. All patients felt that telehealth visits were more convenient than a face-to-face encounter; 53% and 41% reported that the telehealth visit saved them 1-3 hours and more than 3 hours, respectively. Ninety-four percent reported they would definitely like to have a telehealth visit in the future.
