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The Role of Telemedicine in Patient Care

By Elizabeth Kwo, MD MBA – Senior CoverMD Contributing Editor

Summary

In this article, Dr. Kwo looks at the growing role of telemedicine in patient care. Telemedicine is often used when referring to internet medicine, online consultations or interstate medicine. It has moved from a concept to a reality in many practices throughout the United States.

Online patient care is growing rapidly through telemedicine

Healthcare professionals can now provide medical care through interactive audiovisual media, a rapidly growing category of medicine known as “Telemedicine”. It is a term that includes electronic medical record keeping and health information technology and encompasses three main categories:

  • Remote Monitoring
    Simply put, remote monitoring includes technology that can scrutinize a patient’s blood pressure or heart rate and notify providers when additional medical attention is required.
  • Store-and-Forward
    Store-and-forward involves patient data such as lab values or imaging that is compiled and retrieved at a later date.
  • Interactive Services
    Interactive telemedicine allows medical providers to communicate with patients in real-time such as through online communication.

Interactive telemedicine can have a positive impact on a patient’s medical experience

A patient's medical experience is dramatically affected by interactive telemedicine

Of these three categories, the patient medical experience is dramatically affected by interactive telemedicine. Patients who are less mobile (such as seniors or patients bedridden from a surgery) or patients residing in isolated areas can be seen immediately online. Instead of scheduling appointments in advance, or traveling to see physicians, patients can interact with physicians via video conferencing.

Hand-held mobile devices also allow healthcare professionals to notify patients of their lab results or respond to patient requests. The provider can then make decisions about the patient diagnosis and treatment based on a combination of subjective and objective information that they derive online, similar to what would be revealed during an on-site appointment. Clinical activities such as uncovering medical history, performing psychiatric evaluations, and some physical exam assessments can be completed comparably to activities done through in-person visits.

Physician compensation for online patient care

Several healthcare systems are experimenting with compensating physicians for online interactions with patients, such as virtual online appointments and email exchanges through patient portals such as American Well. Patients first complete a brief survey about their chief complaints and symptoms, then the system searches for the best provider to treat these symptoms. Several healthcare insurance companie such as Blue Cross Blue Shield, Aetna, and Cigna now partially or completely cover the costs of online medical visits between physicians and patients. The American Medical Association (AMA) has established two specific Current Procedural Terminology (CPT) codes for online physician and non-physician consultations in medical management.

Since telemedicine is a new conduit for patient care, medical schools and residencies do not have formal training in this area. There are also no specific qualifications or certification processes at present for a physician to perform telemedicine, but physicians do undergo rigorous training before they start using telemedicine.

Patients want better online care options

A recent Intuit Health survey showed that 67% of medical practitioners plan to utilize patient portals, e-communications, or electronic health record systems to provide patients with access to their prescription refills and health information.

The Intuit Health survey also found that:

  • Close to 20% of Americans perceive they cannot easily ask their physicians questions, make appointments or obtain lab results because of physician accessibility.
  • 78% would utilize a secure online system to access their health information.
  • Interestingly enough, 29% of Baby Boomers and 59% of Generation Y’s would consider changing their current physician for one with better online access.
Medical Malpractice Insurance Policy

Telemedicine malpractice case law is not clear-cut at present

While telemedicine is exciting, it is also new and therefore telemedicine malpractice case law is not as clear-cut. Insurance policies are becoming more consistent about the services that the policy covers, as several companies now offer new professional liability insurance policies tailored to meet the unique needs of healthcare professionals and institutions. But the fact remains that regulations concerning telemedicine vary from state to state. To find a policy, insurance providers must remain consistent, therefore state specific medical liability insurance is much more common. Some carriers currently refuse to renew physicians who they believe are practicing telemedicine, but many of them insure physicians because the policy jargon is vague enough. One place to find more information is the American Telemedicine Association, which collaborates with academic medical centers, technology companies, e-health medical societies, and the government to advance the utilization of telemedicine.

Telemedicine Malpractice Insurance

Telemedicine Insurance - Availability of Coverage Availability of Coverage

Currently there are few insurance companies that are open to covering multi-state telemedicine exposures. This is because many carriers cannot write policies in states outside of their state of domicile or the surrounding states for which they have filed rates with the various Departments of Insurance. As such, the best bet is to use a broker who has access to national carriers. This way, the physician can cover, under one policy, the exposures in the states in which he wants to practice today and have the flexibility to expand to additional states in the future on the same policy. It is more cost-effective for the physician as well to have each exposure on the same policy.

Many regional or state specific carriers therefore discourage the use of telemedicine that crosses state lines as they are unable to continue to insure the physician. The physician should therefore never assume that coverage is available in their current insurance situation. Those who do may discover at the time of claim that they are not insured.

Telemedicine Insurance - Assumption of Coverage Assumption of Coverage

Many physicians often falsely rely on their current policy to cover them automatically for telemedicine malpractice insurance but physicians should review their policies carefully to see if coverage is automatically extended for this activity.

Policies can have several areas that address coverage for telemedicine. The first place many physicians go is to the definition of “Coverage Territory” or a similar term. In some cases the definition will read “the entire united States and it’s territories.” Physicians may rely on this to believe that they will have coverage in place in the event of a claim but often times, there are further obligations in the policy that supersede the definition of “Coverage Territory”.

As an example, the policy may state that the physician is covered only in the states in which he/she is licensed. Further, the policy may state that the physician is covered only in the states that the physician has advised the insurer in writing that he/she is practicing medicine. Finally, the policy usually has terms that place the duty on the physician to inform the insurer immediately in writing if he/she performs any procedures or changes any part of his/her practice that was not written on the original application. The latter can propose a problem as many insurers renew physicians year after year without requesting an updated application.

To be safe, the physician should always call their broker when they change specialties, procedures or any part of their practice.

Telemedicine Insurance - Interstate Practice Issues Interstate Practice Issues

There are many interstate practice issues that can arise with telemedicine. Primarily, should the physician be licensed only in the state he/she is or where the patient resides? In all cases the physician should consult the medical board in each state to determine the state requirements. But beware, because the physician’s insurance policy may require the licensure regardless of the state medical board’s answer.

Another issue that arises is making sure the physician keeps the information private when using the internet or a cloud to review or transmit specimens, charts or patient information. The physician should hire a good IT person to safeguard the data, develop best practices for transmissions and email, and check to see if their insurer covers privacy breaches. These types of suits are becoming more prevalent and the exposure to a physician doing telemedicine can be significant.

The future of telemedicine is clear

The trend is clear – patients desire easy access to health providers and clinical information. As concerns about medical liability and medical privacy during e-communications are addressed, physician practices will likely trend towards adopting more telemedicine.


About the Author

Elizabeth Kwo MD MBA - CoverMD.com Senior Contributing Editor

Dr. Kwo currently works at Cambridge Health Alliance as an Internal Medicine Resident. She holds a MD from Harvard Medical School, an MBA from Harvard Business School, and a BA from Stanford University in Human Biology. She has also worked for American Well, a healthcare technology company involved in developing online patient care solutions.

Read Dr. Elizabeth Kwo's full bio



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