Telemedicine, also referred to as telehealth medicine, is the use of information technology to provide clinical healthcare from a distance. The use of telehealth services in the commercial marketplace has rapidly expanded in recent years. The Department of Health and Human Services estimated that in 2018, 60% of all healthcare facilities were using some form of telemedicine. Even if your practice didn't use telemedicine before, it may be an option worth exploring. In the following slides, we'll review definitions, benefits to telemedicine, and some of the available platforms and equipment. We'll also discuss staff roles, documentation, and some tips and tricks to help you and your patient have a successful telemedicine visit. To begin, the terms telehealth and telemedicine are often used interchangeably. Many organizations, including the Federation of State Medical Boards and the American Medical Association, have offered variations on the definition as technology and insurance reimbursement of all. Simply put, telemedicine is the use of information technology to provide clinical healthcare from a distance. Telemedicine is generally associated with the delivery of traditional clinical diagnosis and monitoring by technology and is a subset of the services encompassed by the term telehealth. Telehealth's broader definition encompasses clinical healthcare as well as a wide range of other services, including educating patients and providers and providing disease awareness and wellness. Telehealth uses innovative technologies such as kiosks, website monitoring applications, mobile phone applications, wearable devices, and video conferencing to remotely connect healthcare providers to patients. While telephone conversations, emails, and patient information portals have an important place, real-time audio-video communication tools are ideal and, as such, are reimbursed differently. So much information can be lost without the ability to see the patient. Imagine a patient trying to describe jaw pain versus being able to see them point to a specific area. Whenever possible, choose real-time audio-visual over a telephone call. Let's take a moment for an overview of telemedicine with its benefits. With its potential to overcome workforce and access barriers, telehealth can reduce health disparities for aging and underserved populations, as well as reduce patients' costs and burdens associated with lost work time, transportation, and childcare. According to a study conducted by Red Quill Consulting, Inc., the average cost of a virtual visit is $40 to $50, while in-person care can cost as much as $176 per visit, making the estimated savings $126 per commercial telehealth visit. For an asymptomatic post-delivery appointment within 90 days of delivery, telemedicine may have the potential to benefit both patient and practitioner. Equally impressive were the environmental benefits of switching to a telemedicine model of patient care. Consider the time and powered resources your facility uses simply to prepare an operatory between each patient visit. Busy practices with multiple practitioners can avoid the congestion and bottleneck that can occur by moving short, non-productive follow-ups to telemedicine. Telehealth gives patients living in rural access areas access to more providers and allows them to receive care in their own communities instead of traveling long distances. Publications have documented healthcare improvements such as a reduction in hospital readmissions and measurable improvements in specific patient populations, for example, in diabetics. However, the long-term benefits for our dental sleep medicine patients are not clear due to limited data reported for these outcomes, but as telemedicine advances, the potential is certainly promising. Getting started can begin with establishing an appropriate space in your practice to accommodate telehealth visits. This can be your operatory, a consultation room, or another quiet office space to have clear communication with patients. Ideally, you will want to document your visit within the patient's existing record. Check with the vendor who supplied your electronic health record management system to see if it has an available video component. Your video access must be secure. The use of social media apps such as Facebook would not be considered HIPAA compliant. Consider whether you want your private telephone number released to patients. Doximity allows you to send information securely and dial from your cell phone without releasing your private phone number. It's free, but you will have to provide verification of your license or proof of healthcare position to join. Zoom does offer a HIPAA-compliant version of its software for healthcare. The free and regular paid version to Zoom are not HIPAA-compliant. Zoom was opened in 2011 and wasn't developed as a healthcare application. It has no specifically designed components for the management of patients online, and it certainly wasn't designed to secure patient data. Zoom was not originally created with a consideration for the security and privacy rules of HIPAA. So how did they make it HIPAA-compliant? To answer that, we need to understand a few basics that make online software compliant. The Health Insurance Portability and Accountability Act of 1996, better known as HIPAA, was enacted to protect patients' privacy and ensure they have access to their medical records. Healthcare providers store their patients' personal identifiable information and medical records and are required by law to follow HIPAA guidelines. Most of us are familiar with what that means in our traditional charting and record keeping, but when using software such as Zoom, HIPAA's rules apply mostly to how the patient's personal identifiable information is transmitted, stored, and of course, who has the potential to gain access to it. And this brings us back to Zoom. Who could gain access to your patient's Zoom video sessions? Essentially, what matters here is how the video is routed. Is it directly from your computer to your patients or through a server on the internet? If the video is being directly routed to your patient, it's going to be pretty hard for a third party to gain access. However, if the video is routed through a server, it gets complicated and the company must follow guidelines to ensure their employees who have access to that server are not snooping, even with encryption. Zoom was able to certify that its video is HIPAA compliant because its technology routes video directly between people and not through a server. That said, to record sessions, Zoom does route video through its servers. To get around that problem, instead of developing systems to ensure privacy, Zoom simply turns off that feature for its healthcare users. In short, you can't record the video sessions with your patient through Zoom and be HIPAA compliant. While it would be a very natural assumption to focus exclusively on the video component, the patient's video is only one of the vital components. Remember, HIPAA requires all personal identifiers be secure. For example, if you add your patient as a contact in Zoom, you can send them invitations or schedule a meeting time. And if you're not using the healthcare version, you're likely violating HIPAA. So remember, while Zoom is a very useful software, if you add your patients as contacts, send them meeting invitations, or store any other patient identifiers in your Zoom account, you could be violating HIPAA unless you've paid to use Zoom's healthcare plan. Moving on to scheduling and staff roles. Have your front desk team schedule a day and time for the telemedicine appointment in your typical fashion and consider offering your patients support. Video and videoconferencing may be unfamiliar to some patients. A welcome visit simply provides the patient an opportunity to work through any technical difficulties ahead of time with a member of your team. This hopefully provides the patient a chance to become familiar with the video chat without wasting valuable appointment time. On the designated day and time, have your assistant call the patient from the room you'll be using for your visit. The assistant will gather the updates and document the patient's progress and concerns and then place them on hold. The front desk will mark the patient as having arrived at this time. The assistant will provide you with the updated information and chief complaint. Remind your assistant to document the time the call started and to inform the patient of anyone else in the room. This should be treated no differently than an actual visit to your office with no disruptions. Make the patient the top priority. Just as your assistant did, you should inform the patient of anyone else in the room. If your patient has someone they wish to make a part of the conversation, that can be documented as well within your notes. For example, Mrs. Smith's husband, John, participated in this visit at his wife's request and expressed concerns that my patient wanted me to be aware of. Also, make reference to whether the encounter is a telephone call or a video in your SOAP notes. Contact your lab vendor of choice and ask if they have written home care instructions as well as images of their oral appliances. These can be very helpful for emailing patients. If you elect to have patients adjust their own devices, consider making a short video to demonstrate this on your website. Having a demonstration model that you can access during the patient's telemedicine visit is also very helpful in following the tell, show, do method of teaching. Prior to your first telemedicine visit, try to complete a webcam trial yourself. Look at yourself on the screen to get an idea of what the patient sees. A USB webcam provides a better quality image than the laptop's built-in camera. Make note of the angle, the lighting, and the framing in the room. Your movements are going to be very exaggerated on camera. When you move forward, your face will fill the frame very quickly. Likewise, leaning back is going to make you appear very small in the frame. Remember to check your surroundings for any HIPAA-sensitive information in the background. Try to keep the webcam lens just above your eyeline. This placement will provide a much more flattering angle. Consider your choice of clothing as well. Solid colors will present professionally and with less distraction. If available, wear your lab coat with your name or your practice's name clearly visible. Your video meeting should be conducted from a location that provides a professional background. Even a single piece of poster board taped to a wall can provide an inexpensive, uncluttered field. Start the video visit the same way you would start an in-person visit. Greet the patient, make some small talk, and remember to smile. Try to avoid wearing jewelry that may cause noise when you move, such as a long necklace or bracelets. Be familiar with the components of whichever software you're using. For example, if you and your patient are having difficulty hearing each other during a Zoom webinar, open your chat window instead. Also consider having a pre-printed sign that helps guide your patient's attention to common issues, like accidentally hitting the mute button. Here are some simple recommendations your scheduling team can use with your patients to help make the most of your telemedicine visit. Consider sending these as an email attachment after scheduling their welcome visit. Remember, this may be the first time your patient is using telemedicine, and the components that may seem obvious may be a point of frustration for others. For example, simply changing the internet browser may be what it takes for a successful visit. And finally, as telemedicine's popularity increases, so will the changes and updates to coding and billing. For the latest information on Medicare's position regarding requirements and billing of telemedicine, please visit CMS.gov. And for the latest information on coding and billing during the COVID-19 pandemic, please visit the American Dental Association's website for additional guidance. Thank you.

telemedicine

telehealth medicine

information technology

health disparities

cost reduction