Transcript has been lightly edited for clarity and readability.

Kerry Whittemore: Welcome to M.ED: Medical Education for the Practicing Clinician. I'm your host, Dr. Kerry Whittemore, a pediatrician with the University of Utah Health. This podcast is brought to you by the University of Utah School of Medicine. Today is the second of our two-part series on telemedicine with Dr. Stephanie Lyden, a neurologist at the University of Utah Health. Enjoy.

KW: How do you think telemedicine will change after COVID—hopefully someday it's over—do you think patients are going to want to continue with telemedicine, or are they going to want to go back to in-person and providers?  

Is telemedicine here to stay post-pandemic?

Stephanie Lyden: I think telemedicine is going to be here to stay. I think that we're already seeing that some patients are requesting telemedicine visits and so I think that we're going to have to be flexible in allowing for this hybrid system, where we have both the option of a virtual visit and then in-person visits, and there are pros and cons to both. And there are definitely some cases that should be seen more in-person than over a virtual visit. 

There are a lot of tips I could give even regarding patients from my experience that would benefit more from an in-person visit and how do we educate patients about that as well, within this hybrid system, that I think is going to remain. 

KW: So right now, is it your scheduler that determines who is going to be virtual versus who's in-person, or do you give them a list of these concerns of in-person versus virtual?  

How do you determine which appointments should be virtual and which should be in-person?

SL: Right now, it's been up to the patient, unless it's a procedure that needs to take place, or if there's something more emergent that we're concerned about, because in our clinic, we have to approve any referral, so we can have a little bit of oversight. But in general, it's usually the patient that's deciding. I think going forward though, we will have more guidelines. For example, if a patient is presenting with a neuromuscular problem, this is hard for a scheduler to really differentiate. There might be ways that we could give some structure to this. In a neuromuscular exam, you have to assess reflexes and do formal muscle strength testing. You're not going to be able to get to the same diagnosis over the camera because you can't do that as you would in-person, and so those patients should ideally be scheduled in-person. 

Even with new patient visits, doing a very formal physical exam is important as a baseline. Then, you can use virtual visits for follow-up questions, going over labs, and going over diagnostic testing. Within the public health emergency, we've had to be flexible. Sometimes just seeing a person is better than not seeing them at all. We're initiating some sort of a workup. 

KW: I think some of that depends on the specialty, and then the provider too. In my clinic, there's a lot of internal medicine doctors, and I know our schedulers are telling the patients, everyone's virtual unless you hear from us, and then the providers scrub their schedule and say, "This one in-person, that one in-person, that one in-person", and then the MAs call and change it. 

SL: Right, that is something initially that we were looking over on ours as well, we'd have to do it at least a week in advance, and there were deadlines just to make sure that they were appropriate for that virtual visit and if something was more emergent, that should be in-person. 

KW: How long do you think telemed calls are compared to regular patient visits? Do you think they're the same? We talked about the upfront part taking a lot longer, but do you think the actual visit time when you're with the patient is the same?  

How do telemedicine appointments compare time-wise to in-person visits?

SL: I think that this is really variable because I think some people have cited that they are quicker because you're doing a lot of the screening with your initial scheduling and the MA is doing intake, so that shaves off time. People will say that the patient is more aware of time because they have a clock in the bottom hand of their computer screen and so they're asking more focused questions, versus sometimes if a patient had to travel a really far distance and they're afraid they're not going to see you for a long time, they're going to try to cram in multiple chief complaints that you're trying to answer.So in some respects, people think that virtual visits are actually much faster than an in-person, but then there's others that say because I am having to do a lot of this communication after a visit is done, where I'm emailing the scheduler or I'm emailing my MA for follow-up, and then I also don't have body language to signal the end of an exam, some patients will try to keep you on the camera and have a lot of additional questions. Even just, "How do I schedule this diagnostic test?" In the past, you may be able to have an MA that comes in and can help them through that. So I don't know, I think that It is variable.

KW: For me, personally, I feel like they're longer because of the documentation piece, only because of how our rooms are set up. I feel like I'm really good at still looking at the patient and typing at the same time in the office, but in the virtual setting, I can't type anything and still look at them, basically, because it just doesn't work with a computer. So for me, I feel like I have to do all the documentation afterwards, but that just might be me, I don't know. 

SL: I think that's what we're all just trying to do, although I'm the opposite. I actually feel like when I'm on my virtual visit, I can be typing and looking at them, because I have so many different monitors versus when I'm seeing them in clinic, I feel like it's harder for me to do documentation. 

KW: Yeah, in my clinic, we do most of the virtual stuff over an iPad. We don't have extra monitors. Or sometimes, I do it over my phone, so I'm holding my phone. 

SL: Yeah, as a stroke doc, we have three monitors, which is amazing. Now, I'm never going back. I need to have multiple monitors open up at one time. 

KW: Do you know how many telemedicine platforms are available? 

How many telemedicine platforms are available and how much do they cost?

SL: I don't. It seems like there are new ones that constantly keep popping up. Even within the university, we have MyChart, Zoom, Vidyo, InTouch, and then there's others like Teladoc. There are a ton out there. 

KW: Right. I'm sure that's increased probably since the pandemic started as well, I'm sure. 

SL: Exactly, it has. And I feel like it's probably going to continue. 

KW: At least for the foreseeable future. In terms of cost to a practice or medical group or institution, do you have any idea about how much a telemedicine platform costs? And is it per visit or just some fee per month, or how does that work?  

SL: I think this is a really good question, it's a really complex question. And so, I actually asked one of our system specialists for more information regarding telemedicine platform cost. And so, the answer that I received is that a typical video platform that's purchased from a vendor could be in the ballpark, anywhere from $100,000 to $400,000 annually. 

KW: Wow. 

SL: Though there are many variables that can alter that cost, the additional variable that could add to it is integrating it into your EMR, which can be above the vendor cost by an additional $50,000 to $100,000, depending on the level of integration. But this is, again, numbers for a major health system level integration, versus if you are a primary care doc with a sole practice that is wanting to institute telemedicine, that is going to be substantially less. Because there are so many different telemed platforms out there, that competition is driving down cost. 

There's also different kind of models out there. If it's a subscription-based service, if you would allow for any type of advertisement, you can get a lower cost. Depending on one thing that people think might drive up cost a little bit with competition is the amount of security that’s quoted. In the future, if there's a higher standard, you might end up having to pay more. So, it's really hard to give any kind of algorithms or anything for cost, just because it's so complicated. There are so many things that factor into it. 

KW: Here at the University of Utah, we use Epic, which is obviously used throughout the country. We've had MyChart and Epic for as long as I've worked here. Has telemed within Epic always ben available? I didn't do it until COVID and now they're charging us extra.  

SL: I'm not sure. 

KW: In terms of the security, I've been told that that's the most secure is to use Epic, MyChart, VirtualVisit. 

SL: Yes, those are some of the most secure. 

KW: In terms of the cost for a private clinician, do you have any idea how much that would be? 

SL: I don't. I was even trying to do some research, and some were saying that it could be free for a certain amount of time, up to maybe even $500. But again, it was all over the place so I don't want to throw any numbers out there. 

KW: It probably depends on what part of the country you're in, too, I would imagine.

I was thinking about telemedicine billing. Obviously, for you, it's different being a subspecialist versus being as a primary care doctor. So, if you have a specialist somewhere like you, in Salt Lake City, who wants to do a consult, a provider in a rural area, how does billing work for this? I'm guessing you probably bill the patient or do you bill who you're consulting with for the telemedicine?  

How does telemedicine billing work?

SL: That is another very complicated question because we have multiple different hospitals within our network, and there's different contracts within each hospital and so sometimes there could be a per-click contract versus a block of time of coverage that's adding to a layer of complexity with how billing takes place, because there are also different codes on top of that, for a consult that is from a rural ER doc, that's asking a specialist. We have an entire spreadsheet that goes over the timing for a visit that was done via a consult on telemedicine versus on the phone, and then those codes differ from the patients that I see as an outpatient, like if I'm doing an outpatient clinic at the University of Utah. Because it has become so complicated, we actually have back end coders that help us with this now. So I'm not as privy to all of the ins and outs, but I do know, I have almost 20 different codes on a spreadsheet based off of all of these different variables. So it is extremely complicated within a big network. 

KW: Did you learn anything about this in med school or residency?  

SL: No. I'm a newer attending and actually just last week, I had set up an appointment to meet with a billing specialist because I was like, "This is so complicated. Please give me some additional tips," and so I truly have an Excel spreadsheet I keep adding to, to try to sort through this because I do not feel like I have the foundation to navigate it. 

KW: Right. And that would probably be some practical tips out there for the folks who teach learners as to incorporate this in your training, because general billing was not something that I learned at all as a resident or definitely as a medical student. 

SL: No, so we're offering a telemedicine curriculum annually, and right now it's more for medical students, but there's even talk that residents should get some exposure. And one of the things that was brought up is billing. And sometimes we overlook that, but it's really important for even residents to get some exposure, so then they can at least go back and look things up, and I think it's really important. 

KW: In terms of learners, in general, when COVID started, at least in Utah, the learners got pushed out of the clinics and now most of them are back. With telehealth being a bigger part of the visits, how do you see the role of a medical student and then as a resident in terms of a telehealth encounter?  

What roles do medical students and residents play in telemedicine?

SL: I think if they did receive, through a course, some background on how to complete their telemedicine presence and how to respond in different environments or different situations and cases, it’s important for them to have that foundation so that then when they do have their clerkships, I think that they should be integrated into some of these telemed appointments because I do think telemedicine is here to stay and this is going to be very important for their practice, once they go out and are seeing patients. One of the ways I think that we can do this is, if before your clinic with that medical student, if a provider has time, is to just go over what platform is being used, how that medical student can access your schedule, and then initiate a visit with a patient. Then, the medical student could try to obtain the HPI from the patient, and while the attending is seeing another patient, they're doing this and then the attending joins the student, the student could present the HPI to the provider live, with the patient listening in. 

The provider could ask any other additional qualifying questions, and then they could do an exam together, because I think that's something, at least through our course, students wanted more practice and somebody to walk them through. That way, you develop an assessment and plan together, and you could even have that student help you with sending the patient MyChart instructions with what you just discussed or educational resources. They're getting exposure to the visit and hopefully not adding too much time to the visit for the provider.

KW: This is for a provider who's doing telemedicine, but sitting in a clinic, right?  

SL: Yes, but I honestly think it could be either if you're in clinic or if both the medical student is remote and the provider is remote from the medical student. If the scheduler sets it up where you can have multiple hosts in a visit, this could occur where you're in a conference call when you come together. It doesn't necessarily have to be that the medical student and the provider are physically in the same place, you could do it, where you're all in different locations. 

KW: Right. And just practically, how would it work for a medical student presenting to the attending not in the presence of the patient, because usually the patient isn't there when you're talking to the attending, going over the differential diagnosis, etcetera. How would you do that practically?  

SL: I think for that, then it is going to be where you're having to exchange phone numbers if it is remote, and then the provider is going to have to schedule in, because that is going to take a little bit more additional time. It's going to require the medical student to have to go through everything, which I think is also another way to do it, so that they're developing their own exam and their own assessment and plan, it's just a way that the provider is going to have to structure their day and maybe be a little bit more limited in the amount of patients that they're actually going to be able to see. 

KW: You could put the Zoom meeting or whatever platform on mute while you have that phone conversation and then rejoin it. 

SL: Exactly. When I was in fellowship, I had virtual clinic and usually I would do the entire visit and then I would call the attending and give them the entire history very quickly. You already have a sense of the high points and things for them to look at. I would tell the patient, "I'm going to mute the camera and the audio, and get the attending up to speed," and then they would join and we'd have a three-way conference. Similar to the med student, I would then be typing up all of our recommendations and sending that to the patient as the attending went over the plan. 

KW: Interesting. It takes some practice, and I think as physicians and people in general, can be uncomfortable to do something new that you're not used to, but once you get the hang of it, it probably works well, just like anything else. 

SL: Right. What we've seen is that even within our clinic, a lot of the providers that are really integrating medical students are the stroke providers just because we already do a lot of virtual visits, and the other people are just themselves trying to figure out how to do telemedicine, let alone having a learner with them. I think that it is kind of with your own comfort level and this will continue to evolve as more and more of us are using telemedicine. 

KW: Interesting. Anything else you think a doctor working anywhere should know about telemedicine, anything that we didn't go over?  

Any other telemedicine tips or resources for providers?

SL: Additional resources are sometimes helpful because you might run into a question or something, and to know that the American Medical Association, there is something called the Telehealth Implementation Playbook that has some tips about implementing telemedicine in your practice. There's also something called the HRSA Telehealth Resource Centers, that sub-divides states into chunks, where each telehealth resource center is over that en-catchment area of states, and then they have resources to try to help providers as well within telemedicine. 

SL: There's also the American Telehealth Association that has a lot of useful resources. And then there was recently a 10-week didactic course called Telemedicine Hack that has quick, PDF and recorded lectures that go over different sub-specialists, different primary care docs, how they've integrated telemedicine in so you get some real-world experience. Then there's didactic lectures thatgo over what we just talked about, so telemedicine, presence, billing, coding, even your physical exam which could be an entire lecture. So I think being aware that there's a lot of resources out there for people who need some more information is important. 

KW: Are most of those free or do you have to pay for them?  

SL: A lot of those are free, and I think there's a lot of efforts underway as of right now as well to develop more didactic material. We're involved with an effort to try to also help faculty have some more access at the U, different subspecialties are integrating telemedicine, and then I know the Northwest Regional Telehealth Resource Center, which is the telehealth resource center for Utah, is also working on these efforts and they are, all of the ones I have mentioned so far are free. 

KW: Awesome. And we will put a link to those on the podcast web page. So thanks for talking about those because I didn't know that they existed. 

SL: Yeah, of course. 

KW: Do you happen to know just offhand at the University of Utah, other than the stroke program, are there any other specialties that are well established in telemedicine already, or is it really just you folks?  

SL: So the TeleBurn has been around, I think even a little bit longer than the stroke, and then after that, there's a TeleICU service that's available. We're developing a Teleneurology, which is for emergent teleneurology, and those are kind of more where there's this broad network. There's also something called Project ECHO that has a very big span, but that's more for educational didactics across our big Intermountain Region. And that's another kind of important resource I think people should be aware of, if you're a primary care doc that kind of wants more education on cases that come up or have an interesting case, there's different forums for that through Project ECHO. 

KW: I'm sorry to interrupt, for those specials like TeleICU and TeleBurn, that's more for a provider in that location to consult another provider, it's not a patient directly going to that. 

SL: You're exactly right. That's usuall an ER provider that's contacting our transfer center, and then we'd get them in touch with one of those networks. 

KW: To get guidance on that specific situation. 

SL: Exactly. 

KW: Awesome. Well, it was really great talking to you. I learned a lot and I think our listeners will too, so thanks so much for joining us.