What is telehealth and its future for chiropractors? ‘For the near future, telemedicine may benefit us more as employers than as participants.’
As practice owners and entrepreneurs, the possibility of offering telemedicine may have chiropractors wondering what we could possibly do via telemedicine since our primary services, typically adjustments, require us to actually see the patient in order to render treatment.
For those who practice primarily nutrition and wellness counseling, telemedicine may make more sense. But don’t give up on the idea of offering telemedicine, as some research has shown that after treatment and discharge, providers of physical and rehabilitation services can have a significant impact on patient outcomes and decrease the incidence of future care by keeping in touch with patients and making sure they are following home instructions and encouraging activity.
What is telemedicine?
It depends on who you ask. Different groups consider telemedicine to be distinctly different than telehealth, yet others use the terms synonymously. As telehealth has grown and involved more specialties, more narrow terms are used to describe the type of care that is being rendered depending on the provider type. The term that is most closely aligned with the care chiropractors render would fall in the realm of telerehabilition, or in time, we may see the term telechiropractic or some variation thereof.
According to the American Telemedicine Association’s Principles for Delivering Telerehabilitation Services, telehealth is a broad term used to describe the use of electronic information and telecommunications technologies to support clinical health care, patient and professional health related education, public health and health administration. Terminology used to describe telerehabilitation is similarly broad.
Some terms specifically refer to individual rehabilitation disciplines, (e.g., tele-audiology, telespeech, teleoccupational therapy, and tele-physical therapy). More generic terms, such as teletherapy, telehealth (endorsed by the American Occupational Therapy Association and the American Physical Therapy Association), and telepractice (endorsed by the American Speech-Language-Hearing Association) are also used, allowing for a broader focus on populations and activities, such as educational settings and wellness promotion in addition to rehabilitation.
Trends in telehealth
While telehealth is expanding into many areas, there is still a problem with adoption by patients and providers. This is not unusual for any new technology. If we think back to when the banking industry made the move into mobile banking, it took years to reach the point that most everyone was comfortable with handling their banking online. Now, we see people literally taking pictures of their paychecks to make a deposit into their accounts and transferring funds to pay bills.
Greg Truex, managing director with J.D. Power, stated: “The challenge facing telehealth providers is adoption and demonstrating to their patients that telehealth provides as good, if not better, and a more accessible channel of care than traditional care channels — emergency room, urgent care and retail clinic visits.”
The American Medical Association recently reported that “a national study of insurance claims filed for alternative settings of care found telehealth rocketed up 53% from 2016 to 2017. The growth outpaced other places studied — 14% at urgent care centers, 7% at retail clinics, and 6% at ambulatory surgical centers.
Patient adoption
According to Mike Russo, director of national sales, Employer Solutions, 66% of the population would consider using telemedicine. The group most likely to use telemedicine (74%) were between 18-34 years old, while the group least likely to use telemedicine (52%) were 65 years and older. The primary reasons patients would consider using telemedicine services were time savings and convenience, faster service, cost savings and better access to care.
Unfortunately, there is not enough data specific to chiropractic to determine if telechiropractic will be of benefit to the average doctor of chiropractic and the patients we serve. There are many factors that have to be taken into consideration if you are considering offering telechiropractic services in your practice. These include insurance coverage, licensure, legalities and practicality.
Telehealth coverage
According to The Public Health Institute/Center for Connected Health Policy, the states continue to expand reimbursement policies, though they are not treated in the same manner as in-person visits. Many states limit the types of services covered and even the location of where services are rendered as well as where the patient is located. Some states may require that telehealth services only be rendered in remote or rural areas.
The delivery of telemedicine ranges from live video to storage and forwarding of information, such as email, and remote patient monitoring services. As telehealth has evolved, there are now many states that have implemented documentation, privacy and prescribing standards. This too is typical of emerging technologies where market forces and technical capabilities outpace rules and regulations. In the future, our state boards and regulatory agencies in chiropractic will have to address if and how telechiropractic can be offered. If you are considering offering some form of telehealth services, you will want to review the medical policy of the managed care groups you are part of to see if your services are reimbursable, what the criteria would be for rendering the services and how the services are to be reported.
Telehealth licensure
According to the Center for Connected Health Policy, nine state medical boards issue special licenses or certificates related to telehealth. The licenses allow out-of-state providers to render services via telemedicine where they are not located or allow a clinician to provide services via telehealth if certain conditions are met. Twenty-nine states have adopted the Federation of State Medical Boards Interstate Medical Licensure Compact, which allows an interstate commission to offer an expedited licensure process for physicians to apply for licenses in other states. Medical boards are not the only ones addressing interstate practice. Thirty-four states have a licensure compact for nurses and 26 states have a compact for physical therapists. This too is something our regulatory boards in chiropractic will have to address in the near future.
Legalities
If you are considering offering telemedicine in your practice, you should first check with your state board of chiropractic examiners to determine if telemedicine is considered to be part of your scope of practice. Secondly, you should determine if your malpractice carrier will cover you when offering telemedicine services and to what extent. Also be mindful of restrictions on providing telemedicine care to those patients who might be out of state. Until chiropractic has broad reciprocity or licensure compacts as the medical community has, we will most likely be limited to the states where we hold a license.
Next, you must consider having informed consent even for telemedicine encounters much like you would for your in-office patients. In reviewing many resources on the best practices for telehealth providers, it appears as though the same standards apply whether you have an in-office encounter or online encounter.
Practicality and integration
For our profession, obviously, most of our care requires the patient to be in the office. That said, there are certainly opportunities for us to provide consults to help patients determine if they need to see a chiropractor and/or health and wellness coaching as well as nutritional advice and perhaps functional medicine services.
You must also determine how much time you have to dedicate to offering telechiropractic services. Will it interfere with your ability to see patients or end up taking time away from your family if you are interacting or replying to patients after hours?
Will your current software allow for the capture and relaying of demographics and clinical notes, and do you have the functionality to offer video conferencing and capture?
There are many telemedicine platforms available that may or may not integrate with your software. Pricing ranges from a few hundred dollars per month up to several thousands of dollars depending on the functionality you need. Be very cautious when choosing a platform and make sure it is HIPAA compliant. Google Hangouts, Zoom and others may be popular and easy to use, but you need to confirm that they meet privacy standards.
What is telehealth to the future of care?
Telemedicine is clearly the wave of the future and is rapidly evolving. For the near future, telemedicine may benefit us more as employers than as participants. All of my employees are offered health insurance and telehealth services.
Telehealth has decreased absenteeism and helps us save money. For a low fee per member per month, they can access a physician with no copayment or cost per encounter. With $2,500 deductibles and $50 copays, the ability to consult with a doctor via phone or video conference at no charge helps decrease utilization of services, which drives our premiums, keeps our employees on the job and out of the waiting rooms of their medical providers, and saves them money. Offering this benefit can help in employee retention and loyalty, and help minimize absenteeism due to routine health problems that could be easily resolved with a telemedicine consult.
Ray Foxworth, DC, FICC, MCS-P, is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. He has served as president of the Mississippi Chiropractic Association, former staff chiropractor at the G.V. Sonny Montgomery VA Medical Center, and is a Fellow of the International College of Chiropractic.
