Since the launch of NYP OnDemand, a comprehensive suite of telehealth services, in July 2016, it has already become one of NewYork-Presbyterian’s core service offerings. Creating NYP OnDemand led us to identify and address four key challenges that we believe are inherent in the development of any telehealth program by any health system:
- Liability – Does this new model of care either amplify existing or create novel medical practice liabilities?
- Licensure – Because we take care of patients who reside in many different states, under what circumstances would our physicians need to be licensed in other states for telehealth purposes?
- Reimbursement – Our payer contracts did not address care delivered virtually, and Medicare only reimburses a limited set of telehealth services delivered in certain rural areas. How can providers get paid for telehealth?
- Workflow – Is telehealth just like any other model of care delivery, or do we need to rethink how our providers deliver care?
We tackled these questions through a combination of research (including the assistance of our legal and regulatory departments) and conversations with peers who had experience in the field.
Liability. The question around telehealth liability arose when we contemplated how clinicians would interact with patients virtually. While we believed that our clinicians would be able to provide high-quality virtual care (particularly since it has become common practice for clinicians to interact with their patients informally via text, email, and video chat), we did not know whether these interactions had a potential for greater legal liability as compared to in-person visits. This turned out to be the simplest issue to address — our malpractice carrier confirmed that our clinicians would be covered as long as they were practicing within the scope of their license. We cannot say whether all carriers offer such coverage, so we encourage other health systems to check before launching a telehealth program.
Licensure. Licensure presented a number of challenging issues. In a traditional context, clinicians must be licensed in the state in which they practice medicine — but state medical licensure regulations typically do not anticipate many of the possible scenarios created by telehealth. Two examples are illustrative:
- A physician who is licensed in New York but resides in New Jersey has a telehealth visit from his or her home with a patient who lives in New York.
- A patient residing in New York travels out of state and has a telehealth visit with his or her regular physician, who is located in New York.
We examined these kinds of scenarios, initially focusing on four states that provide our largest volume of patients: New York, New Jersey, Connecticut, and Florida. Unfortunately, after some detailed research (and support from the American Telemedicine Association’s state-by-state guides), we found that regulations vary widely from state to state. This led us to adopt different strategies for each application of telehealth. Our urgent care physicians — a relatively small pool of clinicians — obtained licenses in these four states relatively quickly. Given the larger number of clinicians involved, however, this approach was impractical for follow-up visits, and we consequently limited the geography for this use case.
Although the Interstate Medical Licensure Compact has expedited licensing across the 22 states that are members, this is only a first, and partial, step toward creating a regulatory environment that acknowledges and fosters the delivery of care via telehealth. Examples such as the ongoing legal battle between Teladoc and the Texas Medical Board (only just recently ameliorated by the passage of a state bill waiving an in-person visit requirement) suggest that the country is still some time away from achieving true alignment and administrative simplification.
Reimbursement. Because establishing a comprehensive telehealth program requires a significant up-front investment in technology, and because we continue to deliver care in a largely fee-for-service environment, reimbursement was a key consideration as we planned NYP OnDemand. We learned, however, that resolving current reimbursement issues is likely to be an evolutionary process. Medicare regulations are clear cut: the program reimburses only a certain set of services delivered via telehealth when the patient is located in an officially designated rural physician shortage area. New York State passed a telehealth parity law addressing Medicaid and commercial insurance around the time that we launched our telehealth program. Though the law took the necessary step of protecting patients, it did not mandate reimbursement parity for providers, and it exempted self-insured employers altogether.
This led us to adopt a transitional strategy in the hope that reimbursement would ultimately catch up with this new mode of care delivery. We launched our urgent care offering as a premium cash-pay service because of the access to board-certified ED physicians at NYP. We focused follow-up visits on surgical care, as these interactions are already included in the professional fees for the procedure. Finally, we chose to absorb the expense of our inter-hospital digital consults, as we believe that facilitating rapid access to specialists at our community hospitals not only offers a better patient experience, but it also reduces wait times and increases throughput in our emergency departments and inpatient units. Our investment in this consult service, which is currently focused on behavioral health and pediatrics, has also helped us improve access for disadvantaged populations.
Workflow. Just as with reimbursement, workflow represents an ongoing challenge — one that we will need to reexamine and address continually as NYP OnDemand grows and evolves. This became apparent as we considered a remote patient monitoring program as one of the early use cases for telehealth. While we found that our clinicians were interested in tracking their patients in their homes, they were not eager to take responsibility for responding to out-of-limit patient readings at night or on weekends.
This prompted us to consider a wide range of implementation questions. These included basic operational decisions, such as where to register and document a virtual encounter when the patient is in one facility and the clinician is in another. We also needed to train clinicians on basic telehealth etiquette, such as holding the device at face level so the patient is not looking up the clinician’s nose. Our clinical teams have worked to develop telehealth-specific care protocols — such as how to diagnose and treat common conditions that present to urgent care — prior to launching each new use case.
We also faced a number of broader issues, such as deciding whether to carve out specific time in existing schedules for clinicians to provide telehealth visits, or whether to expect them to be added on to the existing workload. Similarly, would telehealth visits count toward RVU totals, even though they are not reimbursed? As we operationalized NYP OnDemand, we developed initial approaches to these workflow issues — for instance, while our urgent care physicians work dedicated shifts, follow-ups are currently fit into physicians’ existing schedules. We fully expect those approaches to evolve as telehealth evolves from a growing sub-segment to a core component of our care delivery.
As Telehealth Evolves
While these four challenges can be overcome in launching a successful telehealth program, they require serious consideration. They also demand a flexible approach, recognizing that regulation, practice, and culture will all evolve as telehealth becomes a generally accepted mode of care delivery. Our hope is that this fosters a virtuous circle, whereby increased sharing of best practices on the provider side, and increased awareness and demand on the part of patients, will decrease the challenges associated with launching a program — thereby encouraging greater adoption of telehealth by patients and providers alike.