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Why should an allergist/immunologist consider starting a telemedicine service?

Three reasons to provide telemedicine services include (1) provision of more convenient care to current patients who live at a distance, (2) reduction in overhead to achieve cost savings by using less expensive space, and (3) increased access to patients who might not otherwise travel to your practice. Any one or a combination of these could serve as a justification for initiating a telemedicine program1.

1. More convenient care for patients at a distance
     a.    Works best for practices in large rural states or in underserved urban areas that have poor healthcare access.
     b.    Certain populations such as elderly or disabled patients often have difficulty traveling to a medical clinic and may benefit from being seen at home or in a closer facility.
     c.    According to a 2015 study, the mean no-show rate for doctor appointments was upwards of 20%, with an average cost per patient of approximately 200 dollars. Telemedicine technologies can connect patients with the clinician without having to incur long travel times and associated expenses, making it more likely that they will attend appointments if these access barriers are diminished2.

2. Reduction in overhead to achieve cost savings
     a.    Reduced costs can be increased if space is rented part-time and use of clerical staff is shared with other practices.
     b.    In a retrospective study of a TeleAllergy clinic, 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US $58,000 in travel-related costs, and 80,000 km not driven. Patients experience cost savings and increased convenience by avoiding extensive travel3.

3. Increased access to patients who might not otherwise travel to your practice
     a.    There is a potential to recruit patients who might otherwise go to a nearer provider or decide to forgo treatment altogether4.
     b.    This is a great marketing tactic.

References:
1. Shih J, Portnoy J. Tips for seeing patients via Telemedicine. Current Allergy and Asthma Reports (2018) 18: 50.
2. Kheirkhah P, Feng Q, Travis LM, Tavakoli-Tabasi S, Sharafkhaneh A. Prevalence, predictors and economic consequences of no-shows. BMC Health Serv Res. 2016;16:13.
3. Waibel KH. Synchronous telehealth for outpatient allergy consultations: a 2-year regional experience. Ann Allergy Asthma Immunol. 2016;116(6):571–5 e1.
4. Elliott T, Shih J, Dinakar C, Portnoy J, Fineman S. American College of Allergy, Asthma & Immunology position paper on the use of telemedicine for allergists. Ann Allergy Asthma Immunol. 2017;119(6):512–7


Steps involved to start a telemedicine program

1. Determine where patient visits will take place (origination site)
     a.    Options: medical office building/clinic, hospital, patient’s home
           i.    Only restriction on the type of location for origination sites depends on regulations that are specific to the state in which the patient is to be seen. Some states restrict origination sites to specific venues such as within a hospital or other designated medical building. Others allow care to be given in schools, daycare centers, residential centers, and even a patient’s home if appropriate to the type of visit.
     b.    What is needed within the origination site to make telemedicine visits happen?
           i.    Set up a sending room in which the patient can be seen (often a regular examination room).
           ii.    Clinical Telemedicine Cart which runs the Provider Access Software (PAS). This permits video conferencing between a provider and patient or facilitator. In addition to video conferencing, a telemedicine cart should have ports for attachment of digital exam equipment (digital stethoscope, otoscope, high-resolution camera). A specialty specific exam is required to bill for an E&M visit that is consistent with current CPT codes.
           iii.    PAS needs to preserve patient confidentiality.

2. Determine where the provider will conduct the visit (receiving site)
     a.    It is possible for the provider to be located anywhere including at their home. The only requirement is that they have access to a reliable internet connection and there is sufficient privacy to protect the patient’s health information.
     b.    While the provider needs to be licensed to practice medicine in the state where the patient is located, it is not necessary that they hold a license where they are located during a telemedicine encounter.

3. Determine the types of patients which will be seen
     a.    Patients at a distance, initial consultation, established visits, etc.
     b.    Visits that cannot be performed through telemedicine: visits where procedures need to be performed (skin tests, immunotherapy injections, challenges should not be done unless a provider is present at the originating or sending site who is willing to be responsible for treating a systemic reaction).

4. Scheduling
     a.    Depends on how an individual practice tends to schedule its patients
           i.    Tips to help decide on scheduling details:
                 1.    It takes slightly less time to see a telemedicine patient than it takes to see a patient in-person.
                 2.    Documenting in the EMR can be done at the same time as other tasks such as performing a physical exam.
                 3.    Patients tend to ask fewer questions when seen by telemedicine
     b.    Initially, consider scheduling the same amount of time for a telemedicine visit as in an in-person visit. The schedule can be adjusted as needed once the system is in place.
           i.    Also need to consider scheduling time for technology issues that may come up.
     c.    Decide how to block off time for visits
           i.    Option 1: Schedule half- or full-day blocks of time.
           ii.    Option 2: Virtual patients can be scheduled mixed in with in-person visits.

5. Training
     a.    Need to ensure that providers and facilitators are properly trained to use the software and telemedicine equipment.
     b.    Providers should practice connecting to the origination site and using the software to control the camera and digital equipment before patients are seen.
     c.    Providers should also review protocols for coping with software failures. A list of technical support numbers should be provided in case there is a software or equipment malfunction.
     d.    If the patient is performing the visit at a medical site, facilitators should be trained to activate the clinical telemedicine cart and to troubleshoot exam equipment should it malfunction.
     e.    Patients should be given detailed instructions from the provider/staff regarding access for the visit.

6. Seeing a patient via telemedicine
     a.    A telemedicine visit starts when the provider logs into the PAS (needs to be HIPAA compliant and FDA approved). The PAS permits a provider to interact with patients. It helps to have the patient’s EMR open either on the same screen or on a separate screen to refer to and document during the visit.
           i.    Some EMRs open a telemedicine window that is integrated into the application, thus 2 systems are not needed.
     b.    Once a connection is established, the encounter can start. The provider should then conduct the history as they would for an in-person visit.
     c.    After the history has been obtained, a physical examination needs to be performed.
           i.    If the patient is at a medical facility, physical examination can be performed with the use of peripherals (electronic stethoscope, otoscope, etc).
           ii.    Most components of a typical allergy exam involve listening to lungs, looking at tympanic membranes, examining the head, eyes, mouth, nasopharyngeal areas, examining the skin for rashes, and looking for digital clubbing.
     d.    After the physical exam, it is necessary to write orders, prescriptions, and give instructions to the patient to conclude the visit.

7. Other uses for Facilitated Telemedicine
     a.    School setting (can be used for asthma training)
           i.    Using multi-presence technology the parent could join the video from their workplace. This approach allows the student to be seen without having to leave school and the parent to be present during the encounter without having to leave work.
     b.    Inpatient consultations
     c.    Nursing homes
     d.    Prisons

References:
1. Shih J, Portnoy J. Tips for seeing patients via Telemedicine. Current Allergy and Asthma Reports (2018) 18: 50.
2. Liu X, Sawada Y, Takizawa T, Sato H, Sato M, Sakamoto H, et al. Doctor-patient communication: a comparison between telemedicine consultation and face-to-face consultation. Internal medicine (Tokyo, Japan). 2007;46(5):227–32.
3. Portnoy JM, Waller M, De Lurgio S, Dinakar C. Telemedicine is as effective as in-person visits for patients with asthma. Ann Allergy Asthma Immunol. 2016;117(3):241–5.

These links are for research only. They are not endorsed by The American Academy of Allergy, Asthma & Immunology (AAAAI).

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