Telemedicine Workflow and Platform Options: What Would Work Well for Your Practice?

Short abstract

Content available: Author Audio Recording

Abbreviations

COVID‐19

coronavirus disease 2019

CSR

clinical service representative

EMR

electronic medical record

GI

gastrointestinal

HHS

US Department of Health and Human Services

HIPAA

Health Insurance Portability and Accountability Act

MA

medical assistant

OCR

Office of Civil Rights

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As physicians and providers, coronavirus disease 2019 (COVID‐19) has challenged us to transform how we practice medicine in fundamental ways. Prior to the pandemic, many providers had limited exposure to virtual care. Despite interest from providers and patients alike, the tangible physical patient interaction was viewed by many as integral to the practice of medicine. This pedagogy along with insurer restrictions kept telemedicine from being utilized widely.

To facilitate safe access to our expertise and guidance, the pandemic has made it necessary that we rethink the ways in which we deliver care. With this challenge has also come an opportunity to reimagine the idyllic office visit. The hope is that further adoption and sustained use of telemedicine will lead to it being readily available in its current, less restricted form in the future. The US Department of Health and Human Services (HHS) has recently indicated that it will be continuing the telehealth waivers and exceptions for the rest of 2021. ¹

Telemedicine Workflow

In addition to the adaption of the office visit, telemedicine requires reorganization of provider workflows. My experience suggests it is better to have virtual clinics stand‐alone during a clinic block. If schedules cannot accommodate discrete clinic blocks that are only in person or only virtual, I recommend that virtual visits be scheduled at the start of the clinic block and the rest of the block be filled with in‐person appointments. In contrast with delays to starting in‐person visits related to patient travel, check‐in, and rooming, telemedicine visits can more frequently start at the scheduled time. To ensure this, a mechanism to assist patients in troubleshooting virtual technology and access prior to the scheduled appointment is necessary. If patient access cannot be tested prior to the appointment, it is vital to have a system by which either medical assistants (MAs) or clerks contact patients prior to the scheduled start time to assist them. An additional benefit of contacting patients ahead of the virtual visit is that it may also allow for medication reconciliation and update of the problem lists. Some centers have automatic logic flows (bots) to help patients through the setup process. ² Having dedicated clinic staff assigned to this role and having different routes to communicate this information prior to the visit is ideal. Some options include physical mailings, MyChart or electronic medical record (EMR) patient portal‐based messages, and Web site–based information and links. In addition, having technical support available during the virtual encounters, either with a dedicated call center or MA on standby, can be valuable (Fig. 1).

FIG 1.

Ideal telehepatology workflow. Courtesy Rachel Costantino.

Telemedicine Platforms

Several telemedicine platforms are available for electronic real‐time two‐way communication that is non‐public facing for providers and patients. ³ Due to the pandemic, the HHS and the Office of Civil Rights (OCR) are exercising enforcement discretion of Health Insurance Portability and Accountability Act (HIPAA)‐compliant systems, as long as choice of options is provided in good faith. ³ With multiple options now available for telemedicine, I recommend that a HIPAA‐compliant platform be used; all of the platforms presented here are HIPAA compliant (Table 1). I am not specifically endorsing any of the platforms but present them as examples of popular options for telemedicine and telehealth use. It is important to point out that public facing applications, such as TikTok, Facebook Live, and Twitch, are not acceptable modalities to perform telemedicine. ³

TABLE 1.

Summary of Different Telemedicine Platforms

Platform	Cost*	User Interface	Patient Accessibility
EMR‐integrated platforms
Vidyo‐Connect	$$$	Web based	Android, Microsoft, iOS compatible
Polycom	$$$	Web based	Android, Microsoft, iOS compatible
Zoom for Healthcare	$$$	Web based	Android, Microsoft, iOS compatible
Cisco WebEx for Healthcare	$$$	Web based	Android, Microsoft, iOS compatible
Stand‐alone telehealth platforms
Doximity Video Dialer	Free ‐ $	Application	Android and iOS compatible
Doxy.me	Free ‐ $50/month	Web based	Android, Microsoft, and iOS compatible
Zoom for Healthcare	$200/month for up to 10 users, significant if institutionalized	Web based and application	Android, Microsoft, and iOS compatible
Cisco WebEx for Healthcare	$$$	Web based and application	Android, Microsoft, and iOS compatible
Updox	$$$	Web based	Android, Microsoft, and iOS compatible
Vsee	$49/month to $150/month or significantly more if per practice or institutionalized	Web based	Android, Microsoft, and iOS compatible
Remote monitoring platforms
TytoCare	$300 per device set (one‐time fee), $$$	Web based and application	Android, Microsoft, and iOS compatible

^*$, minimal cost; $$, moderate cost; $$$, significant cost.

The following questions may help guide the platform choice for your practice.

What Is the Size of Your Practice?

Whether you are working in a large or small multiprovider practice setting may make a significant impact on what platform to use. Larger practices may require a much more comprehensive telemedicine platform that will need to be standardized among the group. Smaller practices may afford more of a personalized, tailored approach to telemedicine use among the group. In addition, the cost burden of the various platforms should be taken into account, especially among smaller group practices. Different platforms may appeal to group practices based on size as a framework.

Which Providers Will Use Telemedicine?

Autonomy of providers within a practice is a factor to consider when selecting a platform. Some providers and patients have embraced and are facile with telemedicine, whereas others may be reluctant to use it. In a group practice where only certain providers want or need access to telemedicine, some of the stand‐alone platforms presented here may be more advantageous because it would not interrupt current practices for the remainder of the group. If you have trainees who are involved in ambulatory encounters, having an EMR‐integrated multiprovider virtual platform allows precepting to be done within the virtual platform in real time.

How Does the Existing EMR Fit Into Telehealth?

Platforms used for telemedicine range from those that are integrated within the EMR to stand‐alone options. Remote monitoring care platforms with medical tools also exist to augment the video technology to facilitate a remote physical examination.

If a practice does not already use a comprehensive EMR platform that includes online prescriptions, electronic patient messaging, and a scheduling platform, then one might consider a more comprehensive stand‐alone telehealth platform to provide these services for those patients being seen virtually. However, if, in contrast, there is a well‐established, discrete, in‐person flow of processes within the clinic setting, it may be more prudent to use a platform that offers more streamlined services of encrypted two‐way video communication.

EMR‐Integrated Platforms

EMR‐Based Systems, Including Vidyo‐Connect, Polycom, Zoom for Healthcare, and Cisco WebEx for Healthcare

Many health care centers already use an EMR, which has the capability to interface with video platforms. Most centers that are using this feature for telemedicine visits have had to rapidly build and integrate this interface for virtual visits. A typical arrangement in this setup is as follows: the patient downloads a portal application from the EMR system onto an electronic device (smartphone, tablet, or desktop) that is capable of logging in to the EMR patient portal. This allows them to log in and start a video visit from anywhere. Check‐ins occur at or prior to the scheduled appointment time, and patients are directed to a virtual lobby until the provider connects. Providers can similarly connect by accessing the EMR with their electronic device (smartphone, tablet, or desktop). Some providers document simultaneously with the full version of the EMR open on their computer while conducting the video visit. Alternately, if the provider is using a smartphone to connect to the virtual visit, they can document the encounter afterward. Multiprovider opportunities exist for interfacing with patients using these kinds of platforms. This also allows for trainees, multidisciplinary providers, and interpreters to be present at the visit. Moreover, this represents a true advancement for providing accessibility to patients with special needs, disabilities, or those who require interpreter services.

Stand‐alone Telehealth Platforms

Doximity Video Dialer

Doximity Video Dialer (https://www.doximity.com/) is an application‐based program that the provider must download and register to use. This application has the capability to perform video and voice calls. It also allows the health care provider to display an office number or any number of your choosing to the patient, even while using a personal device. ⁴ For this application, the patient does not need to download anything, and it works across both Android and iOS systems. The patient receives a text message with a secure link to join a video call with the provider. This is a great option for less technologically sophisticated patients. Some EMR‐integrated platforms are incorporating a similar system to allow patients to get links directly to their smartphones via text or e‐mail to facilitate access to telemedicine visits.

Doxy.me

The Doxy.me (https://doxy.me/en/) platform can be used by individual providers without a need for institutional or practice group membership. This program requires only a computer, tablet, or smartphone to access. Because this is a Web‐based program, patients can use their phones to access the Web site by using Safari on iOS products and Google Chrome browser on Android products. Patients simply need a Web link to connect to the video visit and much like Doximity Video Dialer, no plug‐ins are required to execute this program.

Zoom for Healthcare

The Zoom for Healthcare (https://zoom.us/healthcare) platform requires a subscription that is purchased by a practice or health care institution, not an individual provider. This is a video conferencing system that has been in use for years, meaning many users may have familiarity with it. It can be integrated into EMR systems or used as a stand‐alone platform to connect with patients.

Cisco Webex for Healthcare

An institution or practice group membership is required to use the Cisco Webex for Healthcare (https://www.webex.com/webexremotehealth.html) platform. This is an encrypted HIPAA‐compliant platform that allows patients and providers to interface through video‐conferencing calls. Unlike several of the other options, the patient and provider must both download a desktop or smartphone application. The platform can be integrated within an EMR system or used as a stand‐alone platform to connect with patients.

Updox

The Updox (https://updox.com/solutions/telehealth/video‐chat) platform is completely Web based, which means neither the provider nor the patient must download anything to gain access. The program must be purchased by a practice group or institution and cannot be used by an individual provider alone. It can be used as an adjunct to an EMR and may benefit those with a less comprehensive EMR system.

VSee

The VSee (https://vsee.com/clinic/solo) platform has been in existence since 2008 to help individual providers create a telemedicine and online presence. It allows encrypted, HIPAA‐compliant video calls through their Web site. Patients can join visits through the independent Web site, which can be branded and tailored to your practice. This platform is likely best for practices without a major EMR system in place or one with individual providers who want telemedicine capability. With Vsee, the patient downloads the application to connect through video visits. This platform creates a URL Web link for the providers to disseminate to patients.

Device‐Enabled Exam Virtual Platform

TytoCare

Much like other video visit platforms, this application‐based solution can be integrated with EMRs or be used separately. It provides real‐time video and audio communication. TytoCare is different in that the patient interfaces with a specific handheld device that is paired with an electronic device, a high‐definition quality camera, an infrared thermometer, and a high‐quality otoscope and stethoscope (Fig. 2). The application also can connect to Bluetooth‐enabled blood pressure cuffs, pulse oximeters, and weighing scales. The application has landmark recognition to aid the patient in aiming and using the medical devices with relative ease. This device enables remote physical examination with vital sign measurements and auscultation, allowing point‐of‐care video visits. These visits can take place at the patient’s home or at a partnering satellite clinic.

FIG 2.

TytoCare platform overview. Courtesy TytoCare Platform.

Discussion

In an ideal world, providers would have had more time to acclimate to the urgent need for telemedicine within this pandemic health emergency. With the modalities presented earlier, it is best to have a consistent approach and sustained support for both practitioners and patients within your practice or institution. Given the robust response by consumers, and the limited and localized availability of providers for subspecialties such as hepatology and transplant, I suspect that telehepatology and telemedicine will continue to be used in some form once the pandemic is over. ⁵ , ⁶ As such, investment in a platform may be prudent and rewarding, not just in the short term but also to facilitate patient access to care in the future.

My own experience throughout this pandemic has demonstrated that rapid change in clinical practice style, coupled with use of new technology, leads to increased time to master these new tools and techniques. Creating infrastructure within clinic‐based practices to support telemedicine is necessary, as is reexamining ways that telemedicine may best support practices and patients.