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Brave new world

October 2011

Published in the October 2011 issue of Today’s Hospitalist

ALTHOUGH HOSPITAL MEDICINE CHANGES at a brisk pace, there’s something a little quaint about our jobs. Despite new medications and sophisticated technology, the actual practice of medicine hasn’t changed much in centuries: We still see patients one at a time in the flesh, face-to-face.

This approach to patient care, while tried and apparently true, can lead to some remarkable inefficiencies. If you believe a recent time-motion study “and we sort of do “hospitalists spend only about 10 minutes out of every hour providing direct patient care. The rest of it is spent dinking around with the EMR and communicating with others.

And then there’s all the time we spend getting from one unit to another. The average hospitalist probably wanders around at least 30 minutes a day. At about $2 per minute, this translates into at least $10,000 a year for climbing stairs, riding elevators and wearing out carpeting.

There’s got to be a better way.

Skype rounding
When you think about it, there aren’t really any technological barriers to immediately reengineering care delivery. There’s already an iPhone in our pocket and a computer in every patient room.

Patient has a new complaint? Skip the page, the return call and the trip to bedside. Why not take a whack at the issue via Skype? You might need to make the trip eventually “there’s that whole stethoscope thing “but probably less often than you think. History typically trumps everything else.

You like? We knew you would, especially if you’re the beleaguered nocturnist holding down a very big fort all by yourself. You could literally lay eyes on patients without moving an inch. Then make your chart entries and enter orders remotely via the EMR. You could even do this from home!

Details, details
If this is such a great idea, there’s got to be a reason why we’re not already doing it. Medical tradition and culture? Maybe, but old dogs can learn new tricks. Probably the biggest barrier “and you likely guessed it by now “is reimbursement. Skype all you want, just don’t expect to get paid for it.

But what about telemedicine? Good thought. It’s arrived but, unfortunately, it hasn’t really found its way into mainstream hospital medicine yet. A brief review of the telehealth guidelines from the Centers for Medicare and Medicaid Services (CMS) will demonstrate why.

The CMS defines telemedicine as “medical services provided between an originating hospital (where the patient resides) and the distant site (where the practitioner is located) involving the use of an interactive telecommunications system.” The agency further notes that the originating site must be located in a rural health professional shortage area (HPSA) or in a county outside of a metropolitan statistical area (MSA). This immediately aces out any evaluations where the patient and provider are located in the same building.

But hospitalists can think of plenty of situations where the patient is lying in a hospital bed and the provider is elsewhere. A good example from our hospital is stroke codes “patient here; neurologist there. While this is undoubtedly very good for patients, it winds up being an unbillable service, at least for the neurologist. Reason? The originating hospital is located in St. Paul, Minn., within one of the U.S. Census Bureau’s MSAs.

Met muster “now what?
But suppose you do meet muster as an originating site. Now what?
In terms of telemedicine, the CMS permits usual hospital care “the stuff you do all day, every day “with some restrictions. Medicare will pay for initial inpatient consultations, follow-up consultations and subsequent care services. (See “Professional service fees for telehealth services,” below.)

The latter is limited to one visit every three days. That means that someone at the originating site needs to be the primary provider, unless you want to eat charges for the intervening days. Some charges for professional services require an E/M code with a telehealth modifier (GT) to reflect care delivered “via interactive audio and video telecommunications system.”

Originating hospitals can also bill a facility fee, which provides additional revenue to the hospital for the ancillary services surrounding the telehealth visit.

Final thoughts
iPhones and Skype are both handy and cool, but they may pose some problems from a telehealth standpoint. Like other forms of health care, telemedicine must fulfill some basic requirements for data privacy. Just

Google HIPAA and either iPhone or Skype, and prepare to get dizzy. Frankly, we wouldn’t suggest resolving this on your own. Put your compliance department or hospital’s legal counsel to work.

Finally, there’s the whole question of the clinical benefits vs. harms of telehealth, which we’ve conveniently avoided until now. Because this is a coding and compliance column, we’ll dodge the issue entirely. For those interested in a little more reading, PubMed has more than 12,000 citations under the subject heading “telemedicine” “300 published in 2011 alone.

David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. He serves as system medical director for addiction medicine and can be reached at dafrenz@healtheast.org. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.