How to Incorporate Telemedicine into Your Sleep Practice

The driving forces in health care in the twenty-first century are improving patient centered care and reducing overall healthcare costs. Scalable technologies and telehealth approaches will continue their rapid ascent toward standard of care due to their clinical and cost effectiveness.

As a sleep medicine professional, you will be required to adapt and adjust to these realities, or you’ll end up as outdated as a punch-card computer system. To succeed on this journey, you’ll need to follow a no-frills road map to seeing your first sleep telemedicine patient—and get paid for it.

Whether you manage your program in-house or hire an outside expert to help you launch, there are seven steps you must follow to implement telemedicine:

1. Begin with the end in mind
2. Know your state regulations
3. Talk to your payors
4. Identify referral sources
5. Select an IT vendor-partner/ secure telemedicine interface
6. See your first patient, document the encounter, and submit a bill
7. Evaluate, adjust and improve

Let’s look at the steps in a bit more detail.

Begin with the end in mind: Clarify your strategic objectives

Telemedicine can do a lot of things—it can expand your catchment area (sometimes dramatically, as in across state lines), reduce travel burden for current patients (including providing regular ongoing care to patients who travel extensively), position you as an attractive partner for relationships with payors, and so forth. Nonetheless, technology has no inherent value to a business.

The value of technology can only be assessed in relation to your organizational objectives. Evaluate technology through the lens of meeting and exceeding your big picture goals. Consider:

• How do you see yourself, and where do you want to lead your organization?
• What are the needs of your patients, payors, and referring providers—and how can technology help meet these needs?
• What are your priorities for service provision, reputation, longevity, and growth?
• How specifically will you measure progress and return on investment?

Know your state regulations

The American Telemedicine Association just held its annual conference here in Baltimore. The ATA estimates that in the US alone, over 3500 sites are connected via over 200 telemedicine networks, and that over half of US hospitals use some form of telemedicine. (The ATA is a great resource: www.americantelemed.org.) Yet the regulations for telemedicine vary from state to state, and legislative initiatives to implement national standards are in their infancy.

The best place to start to learn the lay of your land is your state department of health or board of physicians. Simply visit the website and search for “telemedicine.” You’ll want to confirm the definition of telemedicine and requirements for telemedicine, as well as any statutory regulations regarding the provision of telemedicine.

Talk to your payors

Once you have a sense for regulations in your state, pick up the phone and call your payor representative. I recommend you make this call yourself, as it’s important to confirm that your payor understands the regulations as you do, and that your payor is prepared to accept telemedicine bills.

Here in Maryland (and also in 18 other states and Washington, DC), private insurers are required by law to cover telemedicine services. Functionally, this means that as long as the requirements a face to face encounter are met, and services are delivered through appropriate audio and video means, telemedicine will be a covered benefit. So, pick up the phone and contact your payor representative. You might be surprised what you’ll learn

As an example, when Maryland implemented telemedicine I phoned our friendly CareFirst representative to alert her of our plans in telemedicine. She not only confirmed coverage for telemedicine (for covered benefits), but she also clarified that the originating site can be anywhere in the state of Maryland. In other words, unlike for Medicare and Medicaid, the patient can connect in from his or her home (as opposed to having to be in a medical facility or physician office). Easy for us, easy for patients.

Identify referral sources

As one of few behavioral sleep specialists in a broad catchment area, I frequently receive referrals and patient inquiries from several hours away. Of course this is flattering, but it’s not very practical for most patients to drive hours each way for clinical services that might require half a dozen treatment encounters.

So four or five years ago, when a patient from the Eastern Shore of Maryland called, I agreed that if he drive to see me for a face to face evaluation, then he and I would together determine if telephone follow-ups might be possible. Because his insurance company did not cover telephone services, he agreed to pay out-of-pocket. He provided informed consent, and voila. Telemedicine in the real world. Since then, I’ve of course stayed in close contact with his referring provider, who is attuned to sleep complaints in his patients and lives in an area with few resources.

Of course, this was a reactionary strategy, and you might or might not live near underserved areas. But consider how you can provide value and demonstrate expertise to referral sources and centers of influence, who might refer to you for telemedicine consultation or even second opinion. For example can you help educate/disseminate best practices, or partner in deploying HST? Consider networking at non-sleep functions.

Select an IT vendor-partner

There are a number of HIPAA/HITECH secure telemedicine interfaces, and a detailed review is beyond the scope of this article. All solutions must include real-time video and audio communication as well as recording capacity. If you already have a patient portal, you may choose to house your telemedicine interface within your portal. You should also be mindful of what data is stored, and where, by your service provider.

As a starting point, ask colleagues what software they are using. Seek guidance from your professional associations. Review vendors who secured booths at the recent American Telemedicine Association convention.

See your first patient

Seeing your first patient really is as easy as… seeing your first patient. But before you schedule an appointment, do a couple dry runs. You’ll want to test your software interface (eg, navigation during call, record, pause, store AV file, etc) as well as practice documenting a telemedicine encounter. If your approach to telemedicine is to bootstrap on a budget, ask a colleague or spouse to play the role of patient, and connect remotely. Depending on the level of support you purchase, your IT vendor might provide training and trial runs. Or an outside expert can quarterback the above, or include training as part of a customized solution.

Evaluate, adjust, and improve

Just as with any new program, it’s important to establish your key metrics for success ahead of time so that you can monitor progress and course correct as your program grows. For example, how will you measure clinical outcomes, patient satisfaction, provider satisfaction, and financial return? Because telemedicine is so new, it can be difficult to compare your performance to established, localized benchmarks. There are identified best practices, however. If you’d enjoy a more detailed discussion in a future article, advise the editor.

Don’t fight a megatrend

There are many, many reasons to consider seriously how to leverage telehealth approaches to advance your organizational objectives. Most important is the megatrend of leveraging technology to improve patient-centered care and reduce costs. The forces driving this megatrend are real, powerful, and increasing. Ignore them at your own peril. Or follow these simple steps, take action, test, and thrive.