Telemedicine for Everyone

stethoscope laying down
The tools doctors use every day are changing. Is the smartphone replacing the stethoscope?

As a dermatologist, the possibilities of telemedicine were evident early in my career.  You did not need a patient to make a diagnosis. You just needed a good picture.

Telemedicine was initially promoted as a benefit to patients. It would increase their access to specialty care and surmount geographic barriers. Unfortunately, the only reimbursed format at the time was live interactive video, which was too impractical for widespread use. Patients also had limited access to the technology. Telemedicine languished.  

During this dark time, I was involved with a few unsuccessful start-up telemedicine platforms that focused on direct patient access to specialists. There was a lot learned from the experience but there were no compelling reasons for physicians to adopt the practice.

That changed 2012 when California’s own telehealth law (AB 415) went into effect. Now physicians of all specialties would be beneficiaries of telemedicine. The new law authorized physicians to collect for all forms of electronic interaction. This means you could now be reimbursed for all the free care that you normally give out via the phone or email by using store and forward telemedicine.

The largest benefit, however, is the savings that will occur when physicians no longer have to shoulder the burden of rent, staff, and other expenses when providing care that can be done outside the boundaries of an office. As a result, physicians should explore what aspects of patient care can be responsibly provided online and then try to move patients in that direction. Any progress physicians make in moving portions of their practice online will be protected by the parity law. It requires that online visits be reimbursed at the same full level as an office visit. Telemedicine is now very practical.

Physicians should be wary of many of the telemedicine sites that are out there. Most of the ones you read about in the headlines do not meet the California Medical Association’s (CMA) Principles of Telemedicine. These are the anonymous doctor banks, prescription mills, and sites that use physicians in foreign countries.

Fortunately, there are telemedicine sites that closely adhere to the CMA’s telemedicine standards.  Store and forward platforms like HealthLens (Author is a founder), Azova, and SkyMD enable physicians to practice online in a medically sound and ethical manner.

The primary standard is allowing patients to receive online care from their established physician. This enables follow up with that particular physician and a physical location if an office visit is necessary. Another CMA principle is that the patient’s medical insurance should be used to cover the visit. The CMA adherent platforms also provide secure messaging between patient and physician so the visits can be interactive.

Most commercial insurance companies including Blue Cross, Blue Shield, Cigna and United Healthcare cover store and forward telemedicine. Medicare only covers it in Alaska and Hawaii but there is legislation in progress to expand to all 50 states. To get reimbursed for store-and-forward telemedicine visits, just attach the GQ modifier to your CPT code; e.g. 99203 GQ.

In my practice, I see about 60 online patients per month. Acne, eczema and seborrheic keratoses make up the majority of the conditions I diagnose online. Time sensitive conditions like shingles are not uncommon online diagnoses and it is much easier to get patients on antivirals within that 72-hour window of opportunity when they don’t have to wait for an office visit.

I even see new patients on the internet. According to the Medical Board of California, you can evaluate a new patient online and establish a physician-patient relationship as long as the photo(s) submitted by the patient allows the physician to perform a physical examination that is adequate enough to reasonably make a diagnosis. Established patients, who make up the majority of my online visits, can be evaluated and treated without a photograph. This works out well for prescription renewals.  

Medical research will also benefit from the shift to online care because of the data that telemedicine provides. In the short time HealthLens has been in operation, we have amassed a large library of clinical images, corresponding diagnoses, treatments and, most importantly, outcomes. The granularity of the data will allow for unprecedented levels of analysis.    

Veering from long practiced norms is a troubling process for the medical community. However, the opportunity to eliminate so much of the expense involved in patient care cannot be ignored.  Physicians should be leading the charge in shifting patient care online.  We will be among the beneficiaries.

This is a guest post from HealthLens co-founder Christopher Schmidt, MD.