Meyer, Brett C. MD; Clarke, Christopher A.; Troke, Tana M. MBA; Friedman, Lawrence S. MD
The academic health center (AHC) offers a variety of essential services to its surrounding community: It is usually the health care facility that offers the most highly specialized clinical care providers as well as the most technologically advanced diagnostic equipment and care options, and it frequently serves as the cornerstone of the regional health care safety net. Often, the AHC’s mission includes commitments to community health and community partnerships.1 Although it is unclear how U.S. health care reform might change AHCs’ role or require them to adapt to anticipated structural and reimbursement changes, it is likely that changes in the health care payment system, the development of accountable care organizations, and more widespread exchanges of health information will encourage AHCs to develop stronger bonds with their community and regional partners.
In many geographic areas, there is a disparity between patient need and health care provider availability. Inadequate public transportation, payment systems, and access to care may simultaneously contribute to limiting the specialty services available to many vulnerable populations. Such access problems are generalizable in that they may cut across multiple specialties and apply to both chronic and acute care settings. For example, there is often a need for services such as acute crisis psychiatry, perinatology, and emergency stroke management in which time is critical and treatment may be contingent on evaluations by specialists.2–9
Potential AHC-level solutions for closing geographic distances, improving access to specialty services, and making the AHC more valuable to its community may involve either deploying more care providers to affected regions or potentially offering telemedicine services. Experts define telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.”10 Telemedicine consultations can occur via live, bidirectional, “synchronous” communication, or they can be provided in a “store and forward” mode in which images are created and interpretation is done using the still images or in an asynchronous manner (i.e., not during the patient visit). Radiology has used the store and forward format for years, and other fields (e.g., dermatology,11 pathology12) now have the potential to be practiced similarly.
We believe that telemedicine should be viewed as an extension of the way practitioners care for patients in a more technologically dynamic environment rather than as an entity distinct from standard clinical workflows. For an AHC, telemedicine may involve providing tele-clinical care to patients in remote clinics, remote emergency departments, or even remote critical care units. Telemedicine may serve as a telecommunications portal between hub providers (located at the AHC/specialty location) and spoke providers (located at a remote facility), or even between hub providers at the same AHC. It also includes tele-training for practitioners and tele-education for students, practitioners, patients, and the community. AHC telemedicine services are often supported by a large investment of institutional information technology (IT) initiatives.
There are many successful telemedicine programs at AHCs across the United States.13–21 In this article, we draw from our experience implementing and operating an enterprise-level telemedicine program at the University of California, San Diego (UCSD) Medical Center—a tertiary care and quaternary referral center—to offer recommendations to other AHCs regarding the establishment of such programs. Our telemedicine program has contracted with more than 40 remote locations, offering services in psychiatry, general neurology, HIV neurology specialty care, pain medicine, hepatology, internal medicine, endocrinology, neonatology, and oncology. (There are 15–20 other specialties at various stages of deployment.) We have reflected on our telemedicine program’s structure, strengths, and challenges and describe here the telemedicine elements, or “tele-ments,” that we believe are necessary to develop an enterprise-wide telemedicine infrastructure and are important to consider when developing smaller-scale telemedicine programs.
Below, we detail the tele-ments we consider necessary to garner the benefits of and address concerns related to telemedicine programs. We begin with organizational vision, telemedicine infrastructure, institutional policies and procedures, and medical records management. We next discuss the development of hub and spoke relationships, including the recruitment and training of hub specialty providers, and business plans to address issues of reimbursement. We conclude by considering licensure/privileging issues and requirements related to equipment and space.
Developing an organizational vision is the essential first step in developing an enterprise-wide telemedicine program. Key issues of the stakeholders—including patients, providers, and facilities—should be addressed, as should benefits such as expanding care to the surrounding communities (Table 1). Among the issues to consider are already-saturated specialty clinics and long waits for appointments, the desire to improve community partnerships, financial risk and poor insurance reimbursements, subsequent or “downstream” patient care implications, and legal and malpractice risks. The strategies to address these issues should be tailored to the AHC’s overall strategic clinical vision and should take into account the resources, needs, and readiness of each element of tele-health care that would be required should the AHC head down this path.
An AHC’s telemedicine vision may encompass specific specialties or types of care and should be driven by clear goals. At UCSD Medical Center, the Telemedicine Executive Committee envisions telemedicine as a centralized service that uses innovative technology to provide care to patients, to educate practitioners, and to create scientific knowledge. The committee considers key issues from various stakeholder perspectives before determining strategic directions for the telemedicine program.
At UCSD Medical Center, telemedicine plays a role in numerous clinical departments, so we have developed a process to centralize telemedicine resources. (A decentralized process may be more appropriate for an AHC that is implementing telemedicine in a single department.)
To address our need, we created a telemedicine infrastructure that functions much like a “Department of Telemedicine” in that the telemedicine program has its own organizational chart and budgetary responsibilities. Its director reports to both the medical school’s Office of the Dean and to an executive committee at the medical center. We have found that having AHC leadership champions is integral to successful program development.
As for any other AHC clinical service area, the leadership of the medical school and of the medical center ideally should collaborate to develop an organizational chart that clearly designates roles and responsibilities, including those of the following key telemedicine staff:
* a telemedicine director charged with global oversight of the project,
* a medical director for telemedicine with experience developing, deploying, and using a telemedicine system and expertise in telemedicine care and workflows,
* a telemedicine technical project manager responsible for all technical components (e.g., camera connectivity, selecting telemedicine cart systems/workstations to be used by specialty providers), and
* a departmental business officer responsible for budgeting, billing, reimbursement, service agreements, financial management, scheduling oversight, data management, and model options for programmatic sustainability.
Telemedicine program staff interface directly with clinical department staff. Key roles at the AHC, hub, and spoke levels are detailed in Appendix 1.
Policies and procedures
Because telemedicine is considered a centralized service at UCSD Medical Center, we have developed institutional policies and procedures to ensure compliance and coordinate care across specialties. We suggest this approach to AHCs that offer services for more than one specialty because having individual departments develop rules and create subprograms independently poses potentially significant legal, contracting, and compliance risks and may result in redundant, repetitive, and inconsistent procedures within the AHC.
We found it important to create specific policies and procedures that document the workflow for each clinical specialty. To this end, we created an overall medical center policy (MCP) specifically outlining the acceptable boundaries of telemedicine procedures, workflows, and documentation; developed and obtained approval for telemedicine-specific informed consent documents; created specialty-specific clinical workflows as needed; and created detailed checklists for hub and spoke providers to complete when performing telemedicine patient evaluations. (For samples of these documents and checklists, see Supplemental Digital Appendixes 1, 2, and 3, available at http://links.lww.com/ACADMED/A92.) The workflow for telemedicine evaluations need not be significantly different from standard, nontelemedicine workflows, other than the issue of consent. Patient scheduling, preliminary workflows for assessing vital signs and medication lists, and postevaluation workflows for sending clinic notes to referring providers are likely to follow standard clinical practices irrespective of the telemedicine modality.
Medical records management
Telemedicine triage unit. We recommend establishing a telemedicine triage unit to create a system-wide mechanism for obtaining preliminary medical records via mail, fax, or direct scanning technologies. From a clinical perspective, having previous medical records available before any specialty visit, whether that visit takes place via telemedicine or in person, can make the visit much more productive and efficient.
Medical record documentation. The hub site’s documentation for telemedicine visits should follow the same principles as documentation for any other type of clinical encounter. This should be clearly spelled out in any MCP on medical record documentation of clinical care. The policy should require the hub site to create a unique patient medical record number for each telemedicine patient because the patient may present in the future as a hub ambulatory patient or inpatient. The spoke site should also document the visit in its medical record. If the telemedicine evaluation is recorded, there is no requirement to maintain copies of the actual recording itself, but the decision as to whether to archive such content should be made carefully at the AHC enterprise level.
Electronic medical records interface. Using electronic medical records (EMRs) can help streamline an AHC’s approach to managing telemedicine patients. For example, making a scheduling notation that indicates that the patient will be evaluated via telemedicine allows the provider to understand ahead of time which patients will be seen by which technique. He or she can then shift more easily between types of evaluation visits (even alternating hourly within the same clinic day). Further, preliminary documents may be scanned into the patient’s EMR, permitting site-independent retrieval and review before, or during, the telemedicine evaluation. At the time of the scheduled visit (or acute care moment for emergency evaluations), the patient or health care surrogate can sign the informed consent document, which can be faxed to the consulting hub center or uploaded into the EMR. The informed consent document should be placed in the medical record; we believe the best practice is to include it in the medical record at both the hub and spoke locations. (Although legal requirements for telemedicine informed consent are evolving, we have chosen to continue obtaining written informed consent. At this time, we do not provide telemedicine consults on patients unless we have obtained their consent or that of their health care surrogates.)
From a clinical care perspective, we have found that using EMRs helps both the hub and spoke providers. UCSD Medical Center hub providers are able to leverage the standard telemedicine template language present within the EMR to streamline their telemedicine evaluations and verify that full and complete details are noted in the patient’s record at each visit (e.g., identifying the evaluation as being performed via telemedicine, specifying that the patient is aware that his or her participation is voluntary and that future bedside evaluations may be necessary, applying standardized evaluation language). To expedite information sharing, licensed spoke providers can be granted access to their patients’ UCSD EMRs. This improves communication between hub and spoke providers and, we believe, increases the efficiency of telemedicine patient care.
Hub specialty service and spoke relationship development
Assessing AHC resources and evaluating how these resources fit into the AHC’s overall strategic plan is as important as determining which specialties are needed at the potential spoke sites.
Developing hub specialties. On the hub side, telemedicine champions must determine whether there are specialists at the AHC with availability in the specialty or specialties that can fill gaps in potential spoke partners’ clinical services. The importance of identifying clinical champions who will be interested and effective in developing their departments’ roles in the AHC’s telemedicine program cannot be overemphasized. These clinical champions and AHC business officers should meet to identify potential spoke partners, decide on services to provide and hours/days of operation, establish the medical center locations from which telemedicine services will be provided, determine how telemedicine will fit into the clinical department’s overall workflow, and develop a business plan (see below) that satisfies the stakeholders.
Developing spoke relationships. Spoke organizations take various shapes and sizes. They tend to employ general practitioners (MDs, DOs, NPs, or PAs) and have variable information systems infrastructures. A needs assessment from both the IT and clinical service perspectives should be performed collaboratively by the spoke and hub in order to help develop a common ground for services provided.
When an AHC takes steps to partner with a spoke facility to provide telemedicine services, it is important to optimize any current relationships that exist outside the telemedicine arena. There may be opportunities to modify existing contracts or to leverage existing relationships to incorporate telemedicine. The spoke site should develop a clear business plan as well. In our program, we have collaborated with spoke sites to help them understand their potential expenses and revenues from telemedicine. If spoke sites understand the potential benefits, the telemedicine partnership can be far more successful. It is imperative to make telemedicine training, deployment, operation, and maintenance as simple as possible for spoke facilities. The more operational work that the hub center can do, the more likely the program will meet with success.
Identifying specialists and training staff. Once a specialty is selected, specialty providers should be identified. These providers should be able to easily transfer their clinical knowledge into the telemedicine environment; however, we recommend providing structured training on how to perform telemedicine evaluations (e.g., clinical history and physical exam techniques specific to telemedicine encounters, such as remote methods for listening to the heart or looking at a retina). UCSD Telemedicine has offered educational sessions in all aspects of telemedicine, including practice sessions using telemedicine equipment. Training spoke providers may also be essential. In addition, clinic staff at both the hub and spoke sites should be trained in telemedicine clinic workflows and should participate in mock evaluations before the “go-live” date. Checklists act as effective reminders to ensure smooth and complete telemedicine visits.
Expansion and maintenance. Telemedicine programs usually start out small and, if successful, expand by adding additional specialties. Strong relationships between the hub and spokes (more important, between hub champions and spoke champions) can be a critical success factor.
A successful “go-live” may not always translate into a successful telemedicine program. As much work should be put into the maintenance of a telemedicine partnership as into its deployment. We recommend reassessing the workflow the day after the go-live, again one month after the go-live, and at set intervals throughout the year. Frequently, spoke sites get overwhelmed with nontelemedicine tasks, which results in “spoke fatigue.” This fatigue may adversely affect the volume of telemedicine consults requested, leading to a decline unrelated to the spoke’s clinical needs. Both the hub and spoke must commit resources to assess telemedicine clinics and patient scheduling continually to ensure that the care needed is requested and provided. Finally, success breeds success: The more patients who are seen, the more providers who get input from telemedicine consultants, and the more streamlined the telemedicine process, the more success the program will have. We recommend developing a marketing plan to advertise the successful program.
At the present time, it is likely that an AHC’s telemedicine business plan would not be successful if it were to rely on insurance billing alone to justify the initiative. Store and forward telemedicine operations, especially for radiology, have shown cost benefits in the past,22 and reimbursement for such services likely still surpasses that for real-time consultation techniques. However, only a few third-party insurance carriers currently reimburse fully for live telemedicine evaluations, and navigating this dynamic reimbursement environment is incredibly difficult. Given this reimbursement landscape, other reimbursement possibilities should be considered, and community benefits, research benefits, and even potential downstream revenue should be taken into account. The reimbursement situation may change rapidly with health care reform, though. Numerous stakeholder groups—including the Center for Connected Health Policy, the American Telemedicine Association, and the California Telemedicine and eHealth Center—have invested significant time and resources in making the case for improved telemedicine reimbursement by all insurance companies.
Until a new billing paradigm emerges, an alternative approach is to execute clinical service agreements or contracts between the AHC and its spoke affiliates. Contracts should specify the degree of services to be provided and the methods of payment—that is, whether the services will be provided for block time reimbursements (service agreement model), whether payment will come from a parent agency or from grants, or whether patients’ insurance companies will be billed per encounter (insurance billing model). Service agreements should include details that may become important regarding provision of services, including the following items:
* types and hours of services,
* information that must be received by the hub before scheduling,
* patient age ranges for services
* whether add-on or emergency patients are allowed,
* who is required to be present during an evaluation,
* minimal technical standard requirements and contingencies when there are technical problems,
* expectations regarding patient follow-up, ownership of subsequent care needs, and how spoke providers will be notified about recommendations,
* payment for services, no-shows, and instances of technical failures, and
* whether the hub provider is obligated to accept downstream referral business.
Licensure, privileging, and malpractice
Before implementing any telemedicine program, the AHC should verify relevant state regulations, which differ regarding licensure and privileging of hub providers. State laws require that the telemedicine provider must be licensed in the state where the patient resides. It is UCSD Medical Center’s position that telemedicine providers must be credentialed and privileged at the both the hub facility with which they are affiliated and the spoke facility for which they are evaluating the patient. New Centers for Medicare and Medicaid Services regulations (amendment to the Code of Federal Regulations, Title 42, Section 482.22)23 should make credentialing by proxy a reality and should reduce the complexity of telemedicine privileging.
AHCs have policies in place regarding malpractice and coverage for their providers. It is important that participating hub providers assess with legal counsel their individual malpractice limits and the relationship of their malpractice coverage to any telemedicine services they may provide through their AHC.
Equipment and space requirements
Equipment. A common theme, which we have heard repeatedly, is that remote sites or AHCs have chosen to make substantial initial telemedicine equipment purchases (most often through pilot grant funding) but have not seen these investments translate into the development of successful or sustainable clinical telemedicine programs. For this reason, we strongly recommend that facilities not purchase telemedicine equipment until the key stakeholders have developed plans for sustainability.
An essential part of the formula is understanding how and by whom the equipment will be used. Telemedicine equipment should directly serve the needs of the institution’s clinical (or educational) initiatives. We recommend that stakeholders work with their institution’s IT professionals to create a table that fully describes the desired equipment functionality before purchasing any equipment; the table can then be used to assess characteristics of specific pieces of equipment and how these characteristics would be necessary for the successful implementation of a clinical program in specific specialties. Keep in mind that “telecommunications” and “telemedicine” are not the same, although there are numerous telecommunications systems that can be effective in the medical environment. Also, there is no shortage of telemedicine equipment vendors. Those vendors who focus on the needs of the health care consumer when developing and supporting telemedicine systems are generally desirable partners.
We have listed what we consider to be key telemedicine equipment and added features (List 1), but ultimately a facility’s choice of features and vendors depends on specialty needs. Telemedicine carts can usually be used at spoke sites, and telecommunications workstations can be used at the hub site. In many instances, however, these can be used in different combinations (e.g., cart to workstation, cart to cart, workstation to workstation) depending on the service being provided.
Evaluation space. It is not necessary to dedicate rooms to telemedicine. Initial scheduled telemedicine business may not be sufficient to maximize room utilization, so the space should be functional for bedside evaluations as well. Lighting in the hub-side exam room should be sufficient to allow the patient to see the hub provider’s face clearly; in the spoke-side exam room, lighting should permit the hub provider to see all details of the patient’s examination.
At UCSD Medical Center, our providers evaluate both in-house and telemedicine patients while working in front of EMR monitors. For telemedicine consultations, we use a dual-monitor approach in which the provider is situated between one monitor displaying the patient and another displaying the patient’s EMR. This “catty-corner” arrangement is extremely effective for telemedicine evaluations. Other technologies enable the provider to toggle between the EMR and the patient video image as needed.
Privacy, confidentiality, and security. Privacy, confidentiality, and security are paramount considerations for telemedicine because patients’ personal health-related information is being transmitted, usually via the Internet. AHCs should take steps to address the inherent risks, such as inaccurate communication due to loss of video/audio data or confidentiality breaches due to security intrusions via the Internet. We recommend using telemedicine systems that have a high degree of reliability to minimize risks related to loss of data packets. Similarly, we recommend using systems with a high degree of security encryption, consistent with mandates in the Health Insurance Portability and Accountability Act of 1996.
Especially when providing acute care evaluations, the telemedicine provider should be encouraged to use one of the evaluation rooms set up for telemedicine or to use a laptop-access system from an isolated, private location. If there is any risk of someone else overhearing the interaction between the provider and patient, the provider should use headphones and a microphone to ensure that the conversation is private, even when the telemedicine system employs echo cancellation.
Defining Success and Overcoming Challenges
At the outset of program development, it is essential to determine the measures that will later be used to define “success.” The telemedicine business plan may be built on a number of different potential benefits (clinical, financial, or educational), but the weight of each potential benefit depends on the AHC’s long-term strategic plans. Whatever the rationale for starting the program, all key stakeholders must understand how success will be defined (e.g., expansion of patient care, financial return on investment, community partnership development, teaching opportunities, clinical research, downstream referrals, clinical benefit to patients). For our telemedicine program, we determined that the key measures to track would include net increased patient volume, decreased wait times for in-person appointments at clinics in the same specialty, numbers of new and return visits for telemedicine evaluations, number of telemedicine-specific help desk calls, and downstream business to the AHC.
Developing a successful enterprise-wide telemedicine program is not without its challenges, but adopting a standard approach to implementing and providing telemedicine services will help limit the problems that arise along the way. In our case, numerous clinical departments were interested in implementing telemedicine partnerships with remote facilities, but there was redundancy in many of their efforts. It was initially challenging to inform providers of the newly developed telemedicine infrastructure and established procedures, including those related to telemedicine system security, medical record documentation, and informed consent requirements. Developing a specific MCP, as described above, has helped improve consistency and compliance among providers.
Health-care-related technology is evolving rapidly, and telemedicine is part of this quickly changing field. Critical elements of care—from store and forward dermatology consultations11 to emergency stroke management6—are being provided as telemedicine services. Medical education, training, and conferences are routinely augmented by telecommunications technologies. To prepare for and participate in telemedicine, AHC leaders should understand the related issues. As we have discussed, using UCSD Medical Center’s telemedicine program as an example, one key to establishing a successful telemedicine enterprise is developing a core infrastructure built on a single vision of extending care to patients. Developing relationships with spoke facilities and attracting champions charged with the success of the overall program and individual clinical department initiatives is essential. Understanding and balancing the needs and resources of both the AHC and the remote facilities will ultimately help define the program’s success. The importance of developing a business plan cannot be overemphasized. Finally, stakeholders should remember that telemedicine equipment has limited worth without an overall infrastructure to support a strong program and a strategic plan to guide the initiative.
Many health care institutions are interested in using telemedicine to expand care and specialty options for their patients and those of partner facilities, but they are not sure how to begin or optimize this process. We believe that the key telemedicine elements, or tele-ments, that we have detailed represent essential aspects of developing a telemedicine program and offer generalizable guidance for other AHCs entering the telemedicine arena. Using these elements, AHCs and remote communities can begin to build successful telemedicine connections and, thereby, enhance patient care.
Acknowledgments: The authors wish to thank the University of California, San Diego Medical Center leadership for their support in this enterprise-wide telemedicine initiative.
Other disclosures: None.
Ethical approval: Not applicable.