How Telemedicine Is Influencing Wound Care

Telemedicine is becoming popular in the healthcare industry. There are over a dozen telemedicine companies already working with doctors. Doctors have started seeing patients virtually for their non-emergency visits. 

Telemedicine is playing an important role for management of chronic diseases. After a patient visits for the first initial complete evaluation in a doctor’s office physically, follow-up care could be done virtually for many chronic diseases. Also, if a patient seen virtually needs urgent care, the patient can be urgently seen by an on-call covering physician and could be followed up in the doctor’s office if further care is needed. Many large employers provide telemedicine services as an added benefit to their members.

At centers like Joslin Diabetes Center, doctors have started using virtual visits for follow-up appointments with out-of-state patients. Medicare, Medicaid, some United Health Care plans, and some Humana plans, among others, have approved payment for telehealth services. Furthermore, as telemedicine trends upward, other insurance carriers are also considering to pay for telehealth services. Our speciality of wound care is a referral- based practice. Most states now do not require an initial face-to-face encounter to provide telehealth services. 

There are several reasons that I believe will make telehealth extremely useful in wound care, including:

1. Advent of bundled payment; 
2. Visual nature of wound care; 
3. Fraility of our patients affecting their mobility; 
4. Wound care services are needed in various care settings; 
5. There is lack of trained wound care professionals in various settings especially in rural areas; and 
6. Patients with chronic wounds often transition through multiple sites of care (e.g., inpatient hospital, outpatient wound center, home nursing, home health care, or nursing home), making continuity of care extremely challenging

A Closer Look at Some Terminology Regarding Telemedicine Communication

Synchronous. Occurring in real time, i.e., a two-way consult between a patient and a medical provider.

Asynchronous. Delayed communication or store and forward. For example, a transfer of a diagnostic image or video from one site to another for viewing and consult.

Site of care:

Originating. Refers to the location of the patient and (if applicable) tele-presenter at the time the service is being furnished.

Distant. Refers to the location of the eligible healthcare provider, with no pa-tient location restrictions.

Telemedicine. A synchronous audio/video technology to connect a provider to a patient. These services can be provided by physician, or an advanced practice registered nurse (APRN) and physician assistant (PA) under physician supervision.

Telehealth. Delivery of non-provider services remotely using technology. For example, interpreter services, pharmacy services, diabetes education. These services are provided by a licensed professional counselor (LPC), licensed clinical social worker (LCSW), psychologist, registered nurse (RN), nurse midwife, or dietician.

Remote patient monitoring (RPM). A mobile application or fully managed kit that monitors vital signs, records health survey responses, and allows for video and live chat. These services can be provided by a RN under supervision of a physician or by PA or NP under supervision of a physician.

E-consults. When a provider connects with another provider of patients with asynchronous technology.

Tele-presenter. A tele-presenter is a professional who presents in the originating site alongside the patient to facilitate comprehensive exams under the direction of the provider.

Advantages and Disadvantages of Telemedicine in Wound Care

Clearly there are some advantages of telemedicine. Some of them are as follows:

• System savings due to reduced hospitalizations and care costs;
• Reduces patient costs for accessing care;
• Easy access to referring physicians and specialists;
• Easily accessible to patients—reduces travel time and related stresses for the patient, and makes healthcare more accessible to people, especially to those living in remote areas;
• Improves access to care across socioeconomic and cultural circles;
• Facilitates physician–patient communication over distance;
• Physician perspective—expands patient reach, increases practice reimbursement and volume, brings in specialty services, increases patient loyalty and satisfaction;
• Ability to recruit new patients from established or previously untapped sources (home health services, LTAC, skilled nursing facility and other hospitals); and 
• Establish hospital wound center as a central hub to provide physician telemedicine consultations and patient educational information

Problems facing telemedicine are numerous and need to be resolved before telemedicine becomes widespread. Some of the problems facing telemedicine are as follows:

• Added cost for fast reliable broadband connections, technical training and equipment;
• Complicated policies and reimbursement rules;
• Quackery (how to verify the doctor’s credential on the internet);
• Special licensing requirements;
• Decreased in-person visits can lead to misdiagnosis; and
• Decreased personal care—missing opportunity to hold hands and develop psychological consultation on some other family issues.

Centers of Medicare and Medicaid Services' Position Statement on Telemedicine

According to the Centers for Medicare and Medicaid Services (CMS), “Telemedicine seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.

“Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (for example face-to-face consultations or examinations between provider and patient) that states can choose to cover under Medicaid. This definition is modeled on Medicare’s definition of Telehealth services” (see 42 Code of Federal Regulations 410.78).

Medicare does not distinguish between telehealth and telemedicine. Medicare pays for a limited number of part B services furnished by a physician or practitioner to an eligible beneficiary via a synchronous telecommunications system to a patient at an eligible location. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter.

At this time, Medicare still requires that the patient be located in a health professional shortage area or a county that is not included in a metropolitan statistical area and a clinical site for telemedicine billing. It must occur in a space that is one of the following types of health facilities for telemedicine services to be reimbursed:

• Hospitals;
• Physician or advance practice practitioner offices;
• Critical access hospitals (CAH);
• Rural health clinics;
• Federally qualified health centers;
• Hospital-based or CAH-based renal dialysis centers;
• Skilled nursing facilities (SNF); or
• Community mental health centers (CMHC).

Medicare patients must have video component and only synchronous services are supported in Texas.

Medicare has a approved list of HCPCS/CPT codes for telehealth services. Some of them are listed in Table 1.

An Overview of the Legal Issues Associated With Telemedicine

1. Standard of care. Telemedicine services require same standard of care and quality as face to face services. 

Generally, the standard of care is described as the following, as articulated by the Texas Supreme Court, “A physician who undertakes a mode or form of treatment which a reasonable and prudent member of the medical profession would undertake under the same or similar circumstances shall not be subject to liability for harm caused thereby to the patient.”  

In the telemedicine context, then, the standard of care that applies is that which would apply to the physician providing that medical service if the patient were physically present with the physician.

If the standard of care appropriate for an in-person visit cannot be achieved via a virtual visit, then the use of telehealth should be ruled out as a consideration.  

Several factors should be considered including quality of the visual exam, access to historical diagnostics, medication history, chronic conditions, and the use of/need for a tele-presenter.

2. Physician and patient relationship in a telemedicine encounter. According to SB 1107, a physician is required to establish a practitioner-patient relationship in order to provide telemedicine medical services, but neither SB 1107 or the Texas Medical Board (TMB) explain what is required to establish the practitioner-patient relationship. Generally, a patient-physician relationship is established as a result of a contract, express or implied, that the physician will treat the patient with proper professional skills. Establishing the relationship does not require the formalities of a contract and can arise from the acts and conduct of the parties, it being inferred from the facts and circumstances that there was a mutual intention to contract. The same may be true in a telemedicine context, with the physician agreeing to undertake diagnosis and treatment of the patient, and the patient agreeing to that treatment.

There is no express legal or regulatory requirement that requires a face-to-face or in person examination of a patient in connection with a tele-medicine visit.

3. Stark Law and anti-kickbacks. The federal Stark Law generally prohibits a physician who has a financial relationship with an entity from referring Medicare or Medicaid patients to the entity for certain designated health services, except in certain circumstances. The federal anti-kickback statute prohibits individuals from knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare or other federal payment programs. A physician providing telemedicine services should ensure compliance with these laws and pay careful attention to the equipment, facilities, and third parties involved in implementing telemedicine into the physician’s practice.

4. Licensure-state boundary considerations. When physicians treat patients across state lines through telemedicine, it is usually seen as the physician, not the patient, who is traveling across state borders. The TMB requires that in order to provide telemedicine medical services to residents of Texas, a physician must be licensed to practice medicine. More information on licensing requirements can be found on the TMB’s website.

5. Informed consent or privacy notices for telemedicine services. Texas law requires a physician who provides or facilitates the use of telemedicine medical services, to “ensure that the informed consent of the patient, or another appropriate individual authorized to make health care treatment decisions for the patient, is obtained before telemedicine medical services are provided.” Texas regulations also impose specific requirements for telemedicine regarding providing notices relating to privacy and confidentiality and notices regarding the complaint process for any alleged misconduct.

6. Special requirements for issuing a prescription through telemedicine. There are some standard requirements for issuing a prescription through telemedicine as in-person visits. According to Texas law, for the purposes of being able to establish a valid prescription, the physician must meet particular relationship or technology requirements in one of three ways:

(i) Have a preexisting practitioner-patient relationship in accordance with the applicable rule;

(ii) Communicate with the patient in accordance with a valid call coverage agreement in accordance with Texas Medical Board rules; or

(iii) Use appropriate technology that can provide access to necessary clinical information.

7. Medical documentation and maintenance of records requirement. Physicians providing telemedicine medical services are under the same obligation to keep and maintain an “adequate medical record” as they would if the services were provided in person. 

8. Credentialing/contracting for telemedicine services. All facilities should comply with Medicare and Joint Commission requirements relating to privileges and credentialing. Individual physicians should be aware of the regulations associated with telemedicine privileges at a given facility. Physicians should be able to provide the same quality of service regardless of the facilities they provide the service at. If a physician fails to perform or provides a poor quality of service, the facility can report the physician to the national practitioner database, which might affect the physician’s licensing and malpractice insurance.

Conclusion

Telemedicine can be used as a valuable add-on service to enhance patient care in the speciality of wound care. In person, face-to-face interaction between a physician and patient allows physicians to handle many complex social and psychological issues pertaining to the patient and their family members that cannot be achieved by telemedicine. Telemedicine lacks the “touch,” which has the power of healing. 

Telemedicine presents new opportunities for physicians in their wound care practice. In the future, the wound care center can become a hub for telehealth services connecting home health, skilled nursing facilities, acute long term care and rural facilities. Telehealth may provide needed continuity of care for our complex wound care patients in all settings. Telehealth technology is going to disrupt how we practice in the future and it promises to provide the triple aim of low cost, better quality, and access to our patients. At the same time, many state and federal legal considerations should be looked at before starting telemedicine services. n

Jayesh B. Shah is president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. He is also adjunct assistant professor in the department of community Medicine at UT Health, San Antonio, TX, and president of South Texas Wound Associ-ates, San Antonio. He is also past president of the American Association of Physicians of Indian Origin and the Bexar County Medical Society.

1. Centers for Medicare and Medicaid Services. Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R140BP.pdf.

2. Guthrie S, Guthrie B. Telemedicine. In: Shah JB, Sheffield PJ, Fife CE, eds. Textbook of Chronic Wound Care. North Palm Beach, FL: Best Pubishing; 2018:619–635.

3. State of Texas Medical Board. Available at http://www.tmb.state.tx.us/.

4. Federation of State Medical Boards. Model policy for the appropriate use of telemedicine technologies in the practice of medicine. Available at https://www.fsmb.org/siteassets/advocacy/policies/fsmb_telemedicine_policy.pdf.

5. TMA policy 290.008 Telemedicine Use in Protecting the Health and Welfare of Citizens. Board of Trustees, p 18, I-95; reaffirmed BOC Rep. 3-A-05;

amended BOC Rep. 4-A-15. Available at https://www.texmed.org/Template.aspx?id=43465.

6. TMA policy, for instance, advises physicians communicating with patients electronically to obtain informed consent “regarding the appropriate use, limitations, potential fees, and risk of this form of communication. Consent doc-uments should include explicitly stated disclaimers, and service terms. The consent should establish appropriate expectations between physician and patient, and should become part of the legal documentation and medical record.” TMA policy 290.009 Guidelines for Electronic Communications with Patients. TF Rep. 1-A-01; substitute CC Rep. 1-A-03; amended CC Rep. 2-A-04; amended CPMS Rep. 2-A-16. Available at https://www.texmed.org/Template.aspx?id=43466.

7. Gallo SR. Telemedicine: the link to new value-based payment models. Law360.  Available at www.law360.com/articles/881658/telemedicine-the-link-to-new-value-based-payment-models. Published January 17, 2017.

8. Telehealth. Available at www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html. Last accessed July 2, 2019.