Telemedicine and Its Role in Contemporary Gynecology
Whether they know it or not, most gynecologists have practiced a form of telemedicine in the past, such as by taking phone calls from patients asking for medication refills. In these cases, physicians have either acquiesced and called pharmacies to refill the medications or denied the requests and suggested to patients that they make an appointment and receive a new prescription. The latter action will probably not endear patients, especially millennials, to a gynecologist. Physicians who acquiesce to patients’ phone requests to have prescriptions filled or others seek free medical advice should keep in mind that they are not being compensated for providing those services. At the same time, they are legally responsible for their actions and are motivating patients by rewarding them with a prescription or advice and that they will continue to seek free medical advice without making follow-up appointments. These consequences do not make for good medicine. That’s where telemedicine can be an important adjunct to a gynecologic practice. Gynecologists can be compensated for their phone or video interaction with patients while practicing good medicine, as now there would be a record of phone interactions. This article will discuss the process for implementing telemedicine into a practice with minimal time, energy, effort, and expense.
Application to Telehealth Gynecology
In a busy gynecology practice, many patients do not require an in-person visit for effective care. Table One is a list of patients that could conceivably be managed with telemedicine.
There is even the potential to use telemedicine in low-risk pregnancies. Low-risk pregnant women can benefit from telehealth through routine, at-home appointments with their prenatal providers. Traditionally, low-risk pregnant patients are seen for numerous in-person obstetrical visits to monitor progress which can be managed through the technology of telemedicine. A typical virtual visit for a low-risk pregnancy includes utilizing home monitoring equipment to track fetal heart rate, maternal blood pressure, and fundal height.2
Implementation of Telemedicine OB/GYN in the practice
Practices typically use telemedicine platforms to manage one or both types of encounters: walk-in visits through the practice’s website in which patients do not care which doctor they see, but are only looking for the first available provider, and appointment-based consultations, whereby patients schedule video chats in advance, usually with a specific doctor. Although incorporating telemedicine into a practice may seem overwhelming, it is not as challenging as implementing an electronic medical record (EMR) system, as this requires training, buying expensive hardware and software, and the anticipation that production will be decreased until doctors, staff, and patients are comfortable with the new method of providing medical care. Telemedicine, however, is easy to implement, requires minimal additional equipment, easily interfaces with a practice’s website and EMR system, and will increase, productivity and improve workflow. Your patients will appreciate the option of not having to travel for an appointment.
Most patients and referring doctors are already comfortable with their mobile phones and their digital devices such as iPads, social media, and wearable technology, such as Fitbits. So now is an opportune time to implement a telemedicine service. It is not a question if physicians will embrace telemedicine, but when they will include it as a communication tool.
Getting Started Gynecology Telemedicine
Physicians and their colleagues and staff first need to become comfortable with telemedicine technology. Physicians can begin by using video communication throughout their practice, such as by hosting the next staff meeting using video. They should practice starting and ending calls, and adjusting audio volume and video to ensure a good reception by both the gynecologist and the patient. Without developing confidence in using video technology, physicians will not be able to use it effectively with patients.
To be sure, gaining confidence in front of a camera will involve a very short learning curve. It is common for doctors to experience nervousness and anxiety. For example, a five-minute presentation for patients on a gynecologic topic may require several practice sessions in order to be at ease speaking with no audience or no patient to receive your message. It is easy to become comfortable during practice until the computer’s video camera is turned on. Usually, after five-ten telemedicine visits, you will become comfortable in front of the camera.
Selecting a video platform
Figure One provides a list of the most popular video providers and the advantages and disadvantages of each, and Figure Two shows a list of free video chat apps. Apps are available that can:
- Easily share and mark up lab tests, MRIs, other medical documents without exposing the entire desktop
- Securely send documents over a HIPAA compliant video
- Stream digital device images live while still seeing patients’ faces
Some practices rush into telemedicine even though their computers do not even have cameras! Physicians need to take their time, do research, and review a few programs before selecting one for their practice. This will assure their implementation team has the necessary equipment, including webcams, microphones, and speakers.
Gynecologic practices might consider appointing a telemedicine point person who is knowledgeable about the new technology and can patiently explain it to physicians in the practice. Gynecologists need to keep in mind that video chat is dependent on Internet connections and the requirement for sufficient bandwidth. This means having an Internet connection that is fast enough to carry a large amount of data to provide high-quality images.
Once a team is comfortable using video throughout a practice, it is time to test it out with a few patients and perhaps a few payers. Most patients, especially millennials, are eager to start using video for their medical encounters. Survey research and years of experience have shown that downloading an app is no barrier to adoption. Even if physicians serve a senior population, they may be surprised at how willing they are to have consults via video. According to a recent survey, 64% of patients are willing to see a doctor over video.3 We think that this kind of communication will be even more attractive to younger women who are in the workforce or are providing care for their families and don’t have several hours to make an in-office visit.
Furthermore, physician colleagues, medical assistants, and nurse practitioners will need some basic telemedicine skills. Doctors and staff should be prepared to make video connections seamless for patients. Usually, patients need some guidance and encouragement, such as telling them to check their spam folder for their invites if the invites failed to arrive in their email inbox, adjusting the audio settings or setting up a webcam. In the beginning, gynecologists should make sure they build in plenty of buffer time for the unexpected as certainly there will be some “bugs” that need to be worked out.
Gynecologists should observe and collect patient feedback regarding such questions as:
- What kinds of devices (laptop, mobile) do they prefer using?
- What kind of networks are they using (3G, corporate, home)
- What questions do patients ask?
- What features do they like? What features do they have a hard time finding?
- What do they like or not like about the video experience?
The take-home message is that physicians must have patience and be willing to hold patients’ hands as they become acclimated to a video consultation.
Armed with feedback from patients’ video experience, it is time to start streamlining online workflow. Most practices\gynecologists want to be able to manage video visits similar to the way they manage face-to-face visits with patients. This may mean trying out a virtual waiting room. A virtual waiting room is a simple web page or link that can be sent to patients. On that page, patients simply sign in with minimal demographic information and select one of the time slots when the doctor is available. Typically, these programs are designed to alert the doctors and/or staff when a patient enters the virtual waiting room. Patients have access to the online patient queue and can start a chat or video call when both parties are ready. Such a waiting room model serves as a stepping stone for new practices to familiarize themselves with video conferencing. This approach is perfect for practices that already have a practice management system and just want to add a simple video component.
OB/GYN Telemedicine and the practice workflow
Telemedicine can improve the efficiency and productivity of your practice, however, good time management is crucial for success. Your daily schedule and management of patients will need some changes but does not require significant alterations of your existing schedule and workflow. One of the advantages of telemedicine is the convenience of prompt care and the easy access of patients to your practice which avoids patients going to the emergency department or urgent care center for acute care. Perhaps the best use of your time is to schedule telemedicine appointments at the end of the day when your staff has left the office as no staff is required for conducting a telemedicine visit. Ideally, you should offer a set time to communicate with patients as this avoids making multiple calls to reach a patient. Another advantage of telemedicine is that you can provide care in the evenings and weekends. Before telemedicine, many providers have taken calls from patients and provided advice and not been compensated. With telemedicine you can easily conduct a virtual visit from any location and any computer or mobile phone and ethically receive remuneration for your time and care.
Telemedicine and the Coronavirus
The current healthcare crisis makes implementing telemedicine a potential for enhancing healthcare to gynecologic patients. In the past access to care has been a problem in many gynecologic practices. By having a telemedicine program many additional patients can be accommodated into a busy gynecologic practice. Also, there are going to be patients who have been exposed to the coronavirus and even have a diagnosis of COVID-19 who need to be quarantined can now be managed using telemedicine. It is prudent with the current situation to triage patients and all those patients who are febrile and have respiratory symptoms be encouraged to avail themselves of a virtual visit and not leave their home and come to the office. It is very easy for these patients to have a telemedicine visit without exposing staff.
Many media sources suggest there is a potential to have a shortage in the healthcare workforce capacity. It is going to be part of an occupational hazard that physicians will test positive for the coronavirus and will be required to be quarantined. Physicians who are coronavirus positive do not have to be removed from the workforce. It wouldn’t be unreasonable for a coronavirus positive physician to treat gynecologic patients remotely from the physician’s home. The new environment has opened the coffers of CMS and private payers as they have created a national payment policy in response to Covid-19 where there is parity between an office visit and a synchronous telemedicine visit.
Bottom Line Telehealth Future
Patient-driven care is the future, and telemedicine will be part of it. Patients want to have ready access to their health care providers without having to spend hours for a medical encounter that could be done in a few minutes via telemedicine. It is now time to make the leap to incorporating telemedicine into your practice. In the second article, we will review the proper coding for a telemedicine visit so that appropriate compensation is made for a virtual visit. We also review the barriers to implementing telemedicine visits. The third article will be written with the assistance of two healthcare attorneys, Anjali Dooley and Nadia de la Houssaye, who are experts in telemedicine and have helped dozens of practices and hospitals implement telemedicine and provide legal guidelines to gynecologists who are considering telemedicine. After reading these three articles, the practicing gynecologist will have all of the tools to launch a telemedicine program.
*Dr. Mickey Karram, MD, is Clinical Professor of Obstetrics and Gynecology at the University of Cincinnati and Director of Urogynecology at The Christ Hospital in Cincinnati, Ohio
- Implementing Telehealth in Practice-ACOG Committee Opinion. February 2020. https://www.acog.org/-/media/Committee-Opinions/Presidential-Task-Force-on-Telehealth/co798.pdf?dmc=1&ts=20200227T1826268049
- Mooij MJMD, Hodny RL, Oneil DA, et al. OB Nest: Reimagining Low-Risk Prenatal Care. Mayo Clinic Proceedings. 2018;93(4):458-466
- Gardner, Matthew R et al. “Perceptions of video-based appointments from the patient’s home: a patient survey.” Telemedicine journal and e-health : the official journal of the American Telemedicine Association vol. 21,4 (2015): 281-5. doi:10.1089/tmj.2014.0037.