Is my hospital prepared to offer remote second opinions?
Many hospitals that have relied solely on their brick and mortar facilities are now realizing that their physical location is only a part of the health care arsenal they can wield. While hospital facilities are valuable, rare and difficult to reproduce, they often limit their accessibility to those that are geographically local and sufficiently mobile to take advantage of an in-person visit. Beyond the physical structure, the most valuable asset that the hospital employs are its expert physicians. With the appropriate digital infrastructure, their expertise can be deployed well beyond the four walls of the facility.
When done effectively, remote expert medical opinions can become both an incremental source of profitable revenue as well as a way to market the hospital’s brand well beyond the geographic location. However, there are important factors to consider before employing medical expertise in this fashion to ensure a successful implementation.
Below we will dive into the considerations that hospitals should be aware of when establishing a remote or second opinion practice.
In order to offer medical review and advice remotely, you will need a technology infrastructure that allows you to interact with your patient. Most providers find that there are two different types of interactions that must be planned – synchronous and asynchronous.
Synchronous communication is what most people think of as telemedicine. This usually involves a video capability enabling a conversation between a healthcare provider and a patient remotely. Both parties have to be online at the same time, as a close substitute to a face-to-face in person interaction.
What many providers have not yet considered is that a synchronous interaction is best if it is preceded by an asynchronous one. The asynchronous connection enables the patient to provide prior clinical data, test results, scans or other important information for a physician’s review in advance of the synchronous conversation. Having prepared for the electronic visit, the physician will be better informed and can make more efficient use of his or her time.
When using the appropriate technology, the case created electronically will be a comprehensive record of the patient encounter. Should other specialists, for example a tumor board, need to be involved in reviewing the patient case, the electronic record can be easily shared. This record then becomes the foundation for the patient’s electronic health record to give the full picture to any provider that may need to review it.
Most hospitals deploy administrative staff or non physician clinicians to avoid having their expert physicians getting caught up in time consuming tasks. A remote specialist or second opinion practice also carries a similar administrative burden. The most time consuming (and frustrating) part of dealing with external patients is obtaining and consolidating relevant prior clinical history. A system that can coordinate medical release forms, identify other providers with parts of the patient's records and electronically receive and tag these records to the patient case, will significantly reduce the resources required to offer second opinions remotely.
When staffing a remote or second opinion practice it is important to select administrative candidates with clinical experience to ensure the information collected through your technology is complete with thoughtful questions to which the expert physician can direct his or her review. When the administrative team knows what information is required to populate the case record and can ensure that the patient and his or her referring physician questions are relevant, both the patient and the provider come away from the encounter more satisfied.
Hospitals that have been most successful with remote patient consults have found that there are several things they can do to motivate and encourage their physicians to participate in a second opinion program.
- Ease in use: The top concern should be if the physician can access the patients’ prior history and engage in the review effortlessly. The clinical information should be presented in a seamless fashion, ensuring the case is available from wherever the physician happens to be, whether it is in the hospital or at home or on the road. That means that even DICOM images must be accessible locally to that doctor, often requiring the system be web-based with a web DICOM viewer.
- As mentioned previously, many physicians also like to have the ability to engage the patient via an easily accessible video chat that is HIPAA compliant and FDA approved.
- A notification system that alerts the physician that a case is ready to be reviewed is important to ensure timely review of patient records. The most efficient systems also include gentle reminders to keep case review on schedule.
Not all physicians should be expected to participate with remote patient consults; the best method we have found is to educate the physician about the process in advance and request voluntary participation. Some hospitals find that adding a financial incentive such as a stipend for each opinion rendered is effective to encourage participation. However, more hospitals are finding that remote case reviews are becoming a natural part of the physician’s rounds.
There are legal considerations to understand prior to implementing a remote or second opinion service. It is best to consult your legal department to understand your limitations in your specific region. The largest legal hurdle we have encountered is to ensure that you are permitted to serve patients in jurisdictions where you doctors are not licensed. If this applies to your facility, hospitals have found they can still offer their services by including a local physician with whom your expert physician consults. In that way, the remote physician can relay their expert opinion to that local physician who can then communicate it with the patient. This avoids issues related to an out-of-state physician consulting with a patient.
Beyond the geography issues, it is also important to make your patients aware of the ways a remote consult or second opinion will differ from an in-person appointment, in that there will be no physical examination. Effectively, the opinions rendered will be relying on prior physical test results that may not have been performed by your facility. Your doctors will be relying on those other tests to formulate their diagnosis.
Lastly, to ensure HIPAA compliance, you will need to capture patient permission to obtain prior records from their historical providers and maintain the information you obtain in a secure and confidential manner.
Once you start offering remote or second opinion services, it is important to retain case information for both legal archive purposes as well as for a foundation of a patient health record, should the patient be admitted to the hospital or have an outpatient procedure performed there. The case data and report should have the capability to be easily exportable to your electronic health records system.
Historically, most remote consults were not covered by insurance. This restriction has been somewhat suspended due to the COVID-19 health emergency in the US. But, it is not clear whether the current expansion of coverage will remain in effect post the pandemic. In addition to any applicable insurance, remote consults are typically charged an out-of-pocket fee in advance of remote consults or second opinion requests. Automated debit or credit card payments are preferred to telephone fee collection. Second opinion cases are usually not connected to the hospitals main billing and collection systems, therefore you can expect monthly audit reports to detail the customers and payments made.
Don't let these precautions deter you from getting started with remote consults or second opinions. There is no reason that a hospital can’t start small and test out its preparedness to add remote and second opinions to its arsenal - and begin to build this new revenue generating muscle.