Telehealth has come into focus during the COVID-19 pandemic as physicians face an immediate need to reduce exposure by providing care—or at least triage—remotely when appropriate. Under usual circumstances, telemedicine is comparatively low risk. That said, telemedicine does bring specific risks to patient safety and physician/practice liability. Minimizing those risks calls for adapting daily practice routines around informed consent, documentation, and other standard components of a patient encounter, as well as adjusting the practice’s insurance coverage. The following are seven recommendations for any medical practice starting to provide care via telemedicine: 1. Distinguish between new and established patients. The foundation of care remains the physician-patient relationship. If someone you were seeing before this pandemic calls with a problem, it’s reasonable to speak to them by phone or video chat. With new patients, however, proceed with caution. Likely your state or your insurance carrier usually requires that your first visit with a patient be in-person. During this pandemic, such restrictions may be relaxed—but just because you can treat a new patient by telehealth, doesn’t mean you should. New patients may be more difficult to assess, and are also more likely to be experiencing acute situations not appropriate to treat by telehealth. 2. Maintain privacy. Consider who is in the physical space or within listening distance of the patient-physician conversation when treating patients remotely. This includes other people in their space—and also yours. Physician-patient conversations are confidential. It’s up to the patient to determine who might be with them during that visit, but it’s the physician’s responsibility to discuss confidentiality. Also, let the patient know who from your staff is participating—they may not know who’s in the room. 3. Prepare the patient before the appointment. Talk to your patient about whether it is in their best interests to pursue care by virtual visit. This obviously depends upon your specialty, the patient’s presenting concerns, etc. As always, let patients know that they have a right to stop or refuse treatment. Consider not only your technology, but what patients are using. Have your staff review technology needs with patients before you begin. Receive informed consent from the patient for telehealth treatment. A telehealth-specific informed consent form may already exist within your EHR, or here is a sample informed consent. At minimum, get your patient’s verbal consent to consult by telehealth—and document it—before forging ahead. Agree with your patient what you’ll do if there’s a technology malfunction, whether it’s to resume by phone or have the patient come to the office. Talk to the patient about billing. You may tell them, Here’s what your insurance company says about telehealth. Or, We don’t know what your insurance company will say about telehealth. States and insurers are making a variety of exceptions to their usual rules during COVID-19—but the exceptions keep changing, so billing is a moving target. First and foremost, do what you think is in your patient’s best interest as guided by good clinical judgment. Physicians need to be able to support their practices, but the payment has to come secondary to doing the best for your patient in this environment. The Centers for Medicare & Medicaid Services are posting payment updates. Also, check your state’s health authority website for updates regarding state-to-state licensing issues. 4. Develop your web-side manner. Consider your surroundings as you prepare for video visits. Perhaps the brightly colored and patterned wall-hanging behind you could be distracting. If you’re working from home in what was recently a guest room, turn the camera so that the background is your desk, not the guest bed, for a more professional tone. With newer patents, remember your white coat—and make sure your badge is visible. Clothing does look different on camera than in person, so avoid distracting rainbow effects by choosing solid colors over patterns. A little common sense goes a long way in removing distractions and maintaining a professional tone during telehealth visits. 5. Call on creativity to “examine” patients remotely. Some symptoms and conditions must be evaluated in person. However, a virtual exam may be more informative than you’d think. For instance, one can assess for peritonitis by asking the patient to jump up and down. Musculoskeletal injuries may be assessed using the Ottawa knee and ankle rules. The Roth Score allows a preliminary assessment for shortness of breath by simply asking the patient to take a deep breath and count out loud to 30—potential COVID-19 patients may be unable to get past seven. For more information about remote evaluation tools, start with “The Transition from Reimagining to Recreating Health Care Is Now.” 6. Consider additional insurance needs. Remote conversations with patients mean heightened risk for cybercrime, so consider increasing cybersecurity coverage during this time. Review your business associate agreements with technology providers to understand who will be liable in case of a breach. Privacy liability is critical. Consider adding or increasing business interruption coverage: If you’re primarily delivering care via telehealth, any interruption in your communication technology can be considered business interruption. 7. Acknowledge when telehealth is not appropriate. A physician using best judgment can say to a patient, It’s hard for me to fully evaluate your symptoms using this kind of encounter, and I need you to come in. It’s easier to miss things with telehealth, so when you have that second sense you’re missing something—act on it. Remember that a virtual visit is the next best thing—but not the best thing. If you, in your best judgment, think a physical exam is called for, and you think the risk of them coming to your office is less than the risk of not seeing them, then you should have them come to your office. David L. Feldman is chief medical officer, The Doctors Company and Healthcare Risk Advisors. Source
