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How to Practice Telemedicine

So, you haven’t done any acute care or primary care shit for a while. Maybe you’re a subspecialist in Internal Medicine or an ER provider. Maybe you’re an NP or PA in some specialty. Now you’ve been recruited to practice telemedicine.

The practice of telemedicine is easy and the risk is lower than traditional medicine. But don’t take it lightly because it’s as heavily regulated as any other provider-patient interaction.

Virtual Medicine

The current viral pandemic has shifted all clinical practices online. From orthopedic surgeons to primary care clinics. We are all trying to manage our patients virtually.

We have fought for years with payers to let us perform a virtual practice and get reimbursed fairly. It didn’t make sense for the providers to all commute to the clinic, for the patients to all commute to the clinic, and for staff to all commute to the clinic.

Most of the visits are for rechecks, med refills, or questions about medications. The majority of medical visits aren’t even necessary – they are done so that we can bill and make money.

Imagine the footprint we have on the environment with all of these visits and unnecessary vital checking, driving, glove usage, etc.

Practicing Telemedicine

Practicing telemedicine means that you can still collect an HPI, you can get an ROS, and you can even document a physical exam.

You’ll still come up with an assessment and a plan. You’ll list a DDx and you can prescribe medications and even send patients for imaging, labs, or studies.

The physical exam part is what everyone is hung up on. But when is the last time your stethoscope saved your ass in a QA case, a medical board investigation, or lawsuit?

The practice of telemedicine can replace all the in-office visits which don’t require a critical physical exam, a physical intervention, or a procedure.

Enroll in my Telemedicine Course

Primary Care

Primary care is easy, don’t overthink it. Most patients need some screening tests such as orders for mammograms and some blood tests to screen for high cholesterol and diabetes.

The rest of it is medication management. And if you’re practicing virtual medicine then you’re adjusting blood pressure medication dosages, maybe adjusting some insulin, or prescribing the same old things.

If in doubt, you can simply type in “insulin management” or “hypertension management” and the word “workflow” and then click on the “images” tab in your browser and you’ll see tons of workflows that people have published.

I wish I could say that there is an art to Primary Care medicine. For someone who has been practicing it for a long time, it has all turned into a workflow.

Urgent Care

Urgent Care is simple. Most patients are rather astute and self-triage into the right setting. You’re not going to get chest pain, SOB, or hypotensive on your schedule – can’t recall ever having that.

If you do, it’s often because it’s something rather benign. Most of your cases will be UTI’s, pregnancy issues which are simple, rashes, aches and pains.

Triaging the patient and giving them some advice is all you really need to do. When in doubt, reference Up To Date. It’s only like $60/month, month-to-month. It’s a worthwhile investment.

Physicians Practicing Telemedicine

For physicians who haven’t done telemedicine before or haven’t done the primary care or urgent care stuff, switching to telemedicine can be a bit stressful.

Look, I can’t think of anything better than my telemedicine course. I go through EVERYTHING you need to know. I go over the common diseases you’ll see, how to say no, and what patients to worry about.

For most telemedicine companies you can ask for lots of support from the medical director. If not, ask for more “shadowing” sessions – it’s a great way to get through the tougher cases.

But remember that you don’t have to see everyone. Feel uncomfortable with a particular patient? Just don’t accept the patient visit or tell the patient that you’ll get them someone more comfortable with that particular chief complaint.

APC’s Practicing Telemedicine

PA’s and NP’s … you guys are awesome. You’re really jumping into this telemedicine thing in this time of need. I know because y’all buying up my course, left and right.

You should always have someone else that you can bounce ideas off of. And if you purchased my course, you have access to my cell phone, so text me any questions you have and I’ll get back to you in real time.

Get a simple urgent care booklet which you can buy at any medical bookstore or order on Amazon. It’s a great reference for the most common conditions.

Again, remember, you don’t have to prescribe shit. You can simply reassure the patient which is worth so much.

Finally, once you master telemedicine, create a course and sell it to your APC colleagues.

Prescribing Meds

Don’t prescribe meds! That’s the best advice I can give you. Sure, for obvious stuff like a UTI or med refill, do it.

But you should try to triage patients, give them advice on what to do at home. Don’t get into the habit of giving them something. All of a sudden you’ll be giving out mobic, tessalon, albuterol, and prednisone.

I was able to maintain less than 20% prescribing rates. And it served me very well and my patients left the visit happy. You can do it, but your wording matters. And I go over that in my telemedicine course in detail.

4 Comments

  1. Its been an interesting month at my non-Kaiser medical group as they try to roll out phone and video visits to almost all non-urgent care providers this month. It’s all part of an effort to prepare for the possible and planned surge of patients seeking medical care in a COVID-19 world.

    Mo,

    Great article and resources on telemedicne!

    It’s been a little frustrating (but also understandable) to watch some of the missteps along the way and problems that some of these telehealth companies have as far as scalability.

    But in the end, I think the silver lining with COVID-19 is that it will be a seismic shift that shakes our medical system into a more virtual platform.

  2. anthony

    Do you think medical groups will consider this reimbursable CME?

  3. No lo sé.

  4. I hope that we embrace virtual medicine as a way to have a broader reach. But, like most things in medicine, it will likely be highly over-regulated. Some politician will burn a physician to cite a case of abusing telemedicine and use that to push some bill through, which was likely backed by large medical groups like Kaiser or the UC system. But, what won’t go away is the ability of each one of us having a presence online. You can’t take that away, just like you can’t take away someone setting up shop as a DPC. The only way they can regulate the shit out of telemedicine is by tying it to insurance payments – they’ll leave an opening for anyone who wants their own private virtual presence. And, guess what, plenty of patients are willing to pay cash if they believe that they can save money in the long-term.
    But I hope that physicians will take this time to gain some social traction and build their presence online. The shady monopoly world of facebook has made it tough for other businesses to compete but it has allowed us to advertise our services for next to nothing. A TV or radio or billboard ad might have cost you $25k in the past. Now, you can get your word out to people for $25/month in hosting fees.

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