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Telemedicine Update, Any feedback?

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  • Zaphod Zaphod 
    Participant
    Status: Physician, Small Business Owner
    Posts: 5751
    Joined: 01/12/2016

    I haven’t done telemedicine, but we get a ton of medical advice calls in our ER asking what a rash is and should they come to the ER. I agree telemedicine is not terribly useful, and it’s depressing that Big Medicine is obsessed with it as some kind of miracle, but it’s really great to be able to tell patients that they should call the telehealth line (and pay for it, instead of getting free advice from us) if they can’t decide whether to come to the ER or not.

    At best, I think telehealth functions as a triage system. At worst, it’s just z-pack dispensing.

    Click to expand…

    Big Medicine is obsessed or is it tech companies? Of course they are, new entrants looking for a new way to skim that scales.

    #180502 Reply
    fatlittlepig fatlittlepig 
    Participant
    Status: Physician
    Posts: 743
    Joined: 01/26/2017

    It amazes me that FLP can go to sleep at night or get out of the house in the morning, with such extreme aversion to any form of risk.

    Click to expand…

    nah, not really into high risk low reward type endeavors. you have to think that the type of patients who would seek out a telemedicine encounter is likely looking for something.

    #180554 Reply
    Liked by Zaphod
    Avatar ebotrd 
    Participant
    Status: Physician
    Posts: 14
    Joined: 10/25/2018

    I dont know. You can actually usually get some exam and RR and HR and temp through telemed. And IMHO general appearancr and interaction is the most important objectively whether through telemed.or in.person. Recently asked out biller what our clinic gets for typical 99213 URI simple-type visit. Said dependes on insurer but typical is around $38. Makes $28-$30 look pretty good for telemed which is typically more focused with single chief complaint and less awkward to try to limit it to that vs “oh by the way doc” that we constantly deal with.
    I’m just a dozen or so patients in but most disappointed in the EHR interface. Appears most PMH etc is up to the patient and is often lacking/incomplete as I assume they have No guidance as they might have from an MA in real office.
    Would love any input you all have on how to maximize tax deductions and max saving strategies for this or my other 1099 income. I assume I can save 20% in self 401k and deduct reasonable business expenses. Anything else?

    #180891 Reply
    Avatar familydocPA 
    Participant
    Status: Physician
    Posts: 63
    Joined: 03/03/2017
    Splash Refinancing Bonus

    Unfortunately there lots of opinions here being thrown around here without any basis in fact.

    To those concerned about the risk – that’s a joke to me.  First off, this is pretty simple stuff we’re dealing with. Most people are not so obtuse to think that if they are really sick that they can get away with a phone call.  For the rare ones that are, that’s why we ask about warning signs and symptoms and document.   The stuff we discuss is really low acuity, and you hold the ultimate trump card – anything remotely suspicious and you can make your official recommendation be that they get seen.

    All that being said, if you’re really concerned about risk, just look at the track record.  Teladoc provides 1m/3m malpractice coverage.  Unless something has changed since I got credentialed, neither Teladoc nor AmWell have ever had a single malpractice case brought against them.

    With regards to the time, it all comes down to efficiency.  I used to take 10-15 minutes per encounter, but now that I’ve done several hundred, they go much faster. It’s like anything else – you figure out a system that works for you.  I typically spend between 5-8 minutes on the call, and can usually document while I’m on the phone.

    Most patients are very grateful for the service.  It’s really hard to talk to a doc to answer even a simple question; being able to get one on the phone within 5 minutes is a great service.  I am extremely reluctant to prescribe antibiotics and some people do get upset with me, but to be honest that is the minority.

    It’s an easy gig, good for a couple of bucks while I would be otherwise just watching TV.  Same exact thing that I used to have to do for free (taking home calls for my primary care office).

    #181054 Reply
    Avatar Kencufc 
    Participant
    Status: Physician
    Posts: 21
    Joined: 08/12/2017

    I think my average visit time is more like 8 minutes.  I typically document during that time so face to face time is about 5-6 minutes. Typical diagnoses are mainly URI, sinusitis, UTI, viral gastro, flu, and some chronic med refills. Each company I work with sets a goal of less than 40% visits without an oral antibiotic. Starting out I was surprised to see my % was more like 70%!  I hadn’t worked in a clinic in 3years so I did some education and got my % Down to 35% or so.

    #183398 Reply
    Avatar Panscan 
    Participant
    Status: Resident
    Posts: 785
    Joined: 03/18/2017

    I think my average visit time is more like 8 minutes.  I typically document during that time so face to face time is about 5-6 minutes. Typical diagnoses are mainly URI, sinusitis, UTI, viral gastro, flu, and some chronic med refills. Each company I work with sets a goal of less than 40% visits without an oral antibiotic. Starting out I was surprised to see my % was more like 70%!  I hadn’t worked in a clinic in 3years so I did some education and got my % Down to 35% or so.

    Click to expand…

    So almost half the time the company is ok with you giving abx? That seems ludicrous to me. Do half the people with similar symptoms that go to ED end up with abx? That would seem high to me, and then we would assume telemed patients have a much lower probability of having an actual bacterial infection. Not to mention the ED can do labs and make sure nothing looks horrible to indicate something scarier.

    #183403 Reply
    Avatar Panscan 
    Participant
    Status: Resident
    Posts: 785
    Joined: 03/18/2017

    I dont know. You can actually usually get some exam and RR and HR and temp through telemed. And IMHO general appearancr and interaction is the most important objectively whether through telemed.or in.person. Recently asked out biller what our clinic gets for typical 99213 URI simple-type visit. Said dependes on insurer but typical is around $38. Makes $28-$30 look pretty good for telemed which is typically more focused with single chief complaint and less awkward to try to limit it to that vs “oh by the way doc” that we constantly deal with.
    I’m just a dozen or so patients in but most disappointed in the EHR interface. Appears most PMH etc is up to the patient and is often lacking/incomplete as I assume they have No guidance as they might have from an MA in real office.
    Would love any input you all have on how to maximize tax deductions and max saving strategies for this or my other 1099 income. I assume I can save 20% in self 401k and deduct reasonable business expenses. Anything else?

    Click to expand…

    How do you get HR and temp? Sure you could observe RR although I doubt that’s as easy as seeing someone in person.

    #183405 Reply
    LocumGuy LocumGuy 
    Participant
    Status: Physician
    Posts: 1
    Joined: 01/20/2019

    I am going to start doing telemed consults, I’ve got 5 state licenses. Any idea where I can find prescription “guidelines” and SOAP note templates?

    Thanks!

    #183399 Reply
    Avatar StarTrekDoc 
    Participant
    Status: Physician
    Posts: 1799
    Joined: 01/15/2017

    Time yourself next time you’re in the exam room for an outpatient encounter. You’ll probably be surprised. Time yourself also on the time it takes for you to cut off the patient on hpi.

    For a 99213, you should be done fairly quickly especially with templates in play. The reimbursement is in line of real life …cutting out the overhead.

    Most of these are typical diagnosis at the door stuff and you’ll quickly realize the need for more urgent care hands on, stethoscope on the chest exam requirement. If you miss the warning signs of a septic person on the video a decent few questions…you’re probably in the wrong line of work.

    #183423 Reply
    Liked by Zaphod, HikingDO
    Avatar ebotrd 
    Participant
    Status: Physician
    Posts: 14
    Joined: 10/25/2018

    “How do you get HR and temp? ”
    I talk them through how to check their carotid or radial pulse. Takes a good 30 seconds or so more so my visits are longer than 8 minute guy but I feel its the right thing to do for most visits as i feel a lot less worried about pneumonia sepsis etc if the HR is normal and regular rhythm. A good percentage already know it from their fit bit too. If they dont have a thermometer I just base it on whether theyve been feeling feverish. Not sure what else u can do through a webcam.

    #186264 Reply
    Avatar Blindado 
    Participant
    Status: Resident, Physician
    Posts: 2
    Joined: 02/15/2019

    Thank you for sharing your insight and experience with telemedicine. How are you handling income tax in states other than yours that happen to have a state income tax?

    #190997 Reply
    Avatar PedsHosp 
    Participant
    Status: Physician
    Posts: 13
    Joined: 01/24/2019

    This is something I’ve been looking into as a side gig – is anyone who’s been doing it in pediatrics who’d be able to comment specifically on how it’s been in that population? Feel free to PM me separately too if that’s easier.

    #193457 Reply
    Avatar Peds 
    Participant
    Status: Physician
    Posts: 3789
    Joined: 01/08/2016

    It want my cup of tea. Lots of just asking for Rx.

    #193477 Reply
    Avatar ebotrd 
    Participant
    Status: Physician
    Posts: 14
    Joined: 10/25/2018

    I’m FM, so see a decent number of peds cases in my telemed side hustle as well – maybe 15%-ish.  I’ve only been at it about 2 months so still honing in on my comfort level.  I generally try to approach it like I do when the triage nurse loops me in for a call at my day job (brick & mortar clinic), except there we have some history already in the EHR – with the telemed i do there’s usually like 0 history.  Still there are always the usual various “outs” – recommend ER or urgent care or next business day in person visit with PCP, etc.  I think, if they called me at the office, would I make them come in?  And how quickly?  Actually, I probably tend to stick my neck out a bit more than i should (and probably more than the average doc) for parents’/patients’ convenience and to avoid potentially wasting ER time/expense.  (No malprac suits yet in 20+ years knock on LCD).  There is a forum/community of telemed colleagues to bounce questions off of (though we can’t do so in the middle of a visit unfortunately), so I’ve gotten some good direction there.  Sometimes we have to disappoint.  Like their guidelines are pretty clear they don’t want us to be overprescribing antibiotics (and they’ll actually monitor that on chart reviews) so if a patient has a Centor score for strep that’s in the middle and warrants a RAST, we’re to advise them to go be seen in person to get that done and NOT give amox.  If it’s a UTI in a male, they need to go in, we’re not supposed to treat.  I get the sense they’re expecting (or have already felt) close scrutiny from watchdog groups that expect telemed docs to just write for antibiotics all the time.  We also can’t Rx controlled substances or even ED meds.  All these are good things in my view so far.

    #193629 Reply
    Liked by PedsHosp, G
    Avatar doc8862 
    Participant
    Status: Resident
    Posts: 2
    Joined: 03/28/2019

    Are any of these telemedicine opportunities open to resident physicians?

    #201882 Reply

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