How I Practice Now: Telehealth for Beginners
In this video, Sara Horst, MD, MPH, gives her first-hand tips for using telehealth to treat patients, how to overcome IT issues, and how to handle insurance reporting.
Sara Horst, MD, MPH, is a gastroenterologist and associate professor in the Division of Gastroenterology, Hepatology, and Nutrition at Vanderbilt University in Nashville, Tennessee.
Sara Horst: Hi, I'm Sarah Horst. I'm a gastroenterologist at Vanderbilt University Medical Center in Nashville, Tennessee, and I mostly take care of patients with inflammatory bowel disease.
So, in the face of the COVID pandemic, my days as a doctor who takes care of patients with IBD has drastically changed in a matter of a few weeks, as I'm sure most everybody who's listening has similar feelings of.
There's been intense work within my institution to move everyone to telehealth. I practice in a state where this wasn't really feasible before because of insurance constraints. So, we really had very little experience.
With a lot of teamwork and a lot of patience, we've actually been able to move completely to telehealth within a matter of 2 weeks. Our team’s mostly working from home. And so I thought I'd share a few tips about what we've learned and things that we're learning daily as we try to do this in unprecedented times.
I'd really encourage people to look at different society updates, such as ACG. ACG in particular has been running some email blasts that have been really helpful that I've been watching. And then also other websites have been helpful.
Some tips from that I learned when we were trying to get this set up over the past few weeks, was number one: Just get a platform and stick with it. There's a lot of ways to do it. And the technology is rapidly improving.
For me, I found one and sticking with it has made the learning curve easier for me when I'm then trying to do IT support for my patient as we're trying to get connected with Telehealth.
I think understanding your state and licensing restrictions about seeing patients outside of your state is important. That's something that we learned pretty quickly. Our institution was able to obtain emergency medical licenses for a neighboring state where we see a lot of patients. So that's been helpful. That's something that you need to pay attention to.
Understanding the ins and outs of billing is really important. It's probably different for every state and probably even region, but make sure you understand in particular what modifiers you should use. So for a regular clinic visit, a telehealth visit, we use what the typical billing that we used to use we add a GT modifier.
And because we're in a state that typically has not approved telehealth, we also use a CR modifier, which is catastrophic modifier. This may be different for you all.
We also had to learn what the phone-only billing codes were and actually have our health IT team put those into the EMR. They weren't even available for us.
We're currently doing mostly video telemedicine visits. I find that patients actually really liked that platform, and I like it too. I like to actually see the patient when we're talking to each other. So, if I can, I do still try to start with that.
If you're just starting out, I would definitely recommend not to do too many visits in one day. I really cut down my schedule for the first 2 weeks. I moved new patients to the afternoon and return patients to the morning, because I feel like those are 2 different sort of telehealth issues, and I wanted to keep those separated.
One of the things that we learned, and I think this is one of the best things that you could do, is to try to figure out a mechanism for getting adequate instructions to your patients beforehand, so you're not trying to troubleshoot all right there. For instance, I gave a 3-page little slide handout to our scheduling staff, our MAs, our nurses, anybody who might talk to the patient before the visit to help them understand what technology the patient's going to need.
Our institution built a webpage that we send our patients to beforehand. That just got up and running and that's been very helpful as well.
One thing we have just started doing is trying to help our staff do a short intake before actually start the visit, so that meant reconciliation and a little bit of history is done. This may not be feasible for all practices, but I think, in particular for the new patients, if there's any way for you to make that available, that's important.
For me, stable-return telehealth visits I can comfortably do in 20 minutes. If someone sick or for a new telehealth visit, I’m finding those are taking actually a little bit longer than an in-person visit would take, so I'm leaving at least an extra 10 to 20 minutes on my schedule than I would have if I saw the patient in person.
I do find, especially for new telehealth visits, that billing for time is easiest, because there are some constraints of the physical exam elements and review of system requirements to really get to those higher-level visits, if that's something you're needing to do.
So, on the day of the visit, I've learned to just try to stay calm, cool, and collected. IT issues are going to happen. I, at this point, spend less than 3 minutes trying to fix it. If I can’t, I turn to a phone-only visit and I find that works well.
One other thing I found is that I really set an agenda. I think people might meander a little bit more on phone calls and video visits, so I just try to help them understand that I've got a lot of patients lined up after them. Something like “HELLO. How are you? We’re scheduled for 20 minutes today, so I really want to make sure we get through everything.”
I roughly set out what I want to talk about. I offer my spiel about what's happening with the COVID pandemic kind of right off the bat, so they can then ask questions for me.
About the COVID pandemic, I think there's very helpful and ever-evolving information about this. For IBD, most experts are recommending that our patients currently stay on their current therapy. I explain to patients if they stop their medicine that's keeping them in remission, a flare or need for prednisone would put them at very high risk for poor outcomes if they did get COVID.
I frequently visit websites like COVIDIBD.org, who's giving updated information. I appreciate recent guidelines that are put out by groups such as the International Organization for the study of IBD, and our group continues to share information so that we can stay on top of this.
Of course, this is a case-by-case basis, and some people may be appropriate to decrease immunosuppression at certain points. I'm trying to quickly taper pregnant zone and use it as infrequently as possible. But that's why I find telemedicine so helpful in these times. I find it's best to talk face-to-face with my patient about these issues.
I know they have a lot of anxiety and need support not only for medical advice, but sometimes just to listen a little bit. So, given that I've got decreased endoscopy time, I've got more time to do these visits and hopefully help allay concerns and make sure that my patients are on the right medicines.
The last thing I'll say is, I've learned that some people will have strengths in this area, getting things set up, so I encourage you if you're one of those people to consider leading the charge for your group. Having partners to work with and troubleshoot while I'm going through this was really important.
I really hope when this is over that insurance companies and regulatory agencies will keep this more this option of telemedicine more open for our patients, as I think it's a really important tool that will have going forward.
I just want to thank you for listening, and I hope everyone stays safe and healthy.