Practice Management Telemedicine

You are already doing Telemedicine!
By: Rita A. Jung Johnson, DVM, MPH – St. Joe Veterinary Hospital – Evansville, Indiana

What is telemedicine anyway?
It took us a while to realize it in our practice. We were already spending time doing telemedicine.  Telemedicine is any use of technology to perform functions of healthcare diagnosis, prescribing, and/or communication.  This includes, but is not limited to, phone calls, email, text messaging, video calls.
Here are two things to remember most as you read through this….
1. You are already doing telemedicine.

2. You can structure it to suit you.
How many times do you respond to a text?  Or an email? Interpreting pictures or videos?  Advising on specific problems with your unique knowledge? If you answered yes to any of these, you are already doing telemedicine.  You may simply start invoicing for this time as a Telemedicine Consultation and you don’t need to read further.  In my experience, I would encourage use of a telemedicine platform.  There are many options and all will provide you a free demo and discuss the details of their platform.  It takes a little time to investigate them, but then you choose what suits your needs best.  With a structured platform in place, you can better create boundaries that allow you to be compensated for your time and expertise while still providing a service that allows personal communication and maintaining your relationships with your clients.
To get you started, DVM360 took a look at a few for you: www.dvm360.com/view/comparison-veterinary-telemedicine-and-smartphone-apps

Maybe this scenario sounds familiar to you:
A staff member answers the phone and puts a client on hold.  Your staff member brings a question to the doctor while the client is waiting on the line. Non-urgent questions are coming urgently from

all directions while you are trying to stay focused on the patients.  The time spent transitioning from phone or email questions to in-patient care is inefficient time.  Our support staff standing in the doorway awaiting our immediate response is an inefficient use of their time.  Our veterinary nurses and assistants waiting in the treatment room for direction on a patient in hand is an inefficient use of their time.  Most veterinarians can probably relate. Our time, communication, and knowledge are our most valuable assets in this profession. Yet, the time and expertise the doctors spend reviewing the patient’s record and making a treatment plan or recommendation for the incoming phone calls and emails may not be compensated.  If any of this sounds familiar, the telemedicine you are currently providing may be distracting from your other patients, and likely distracting from your family and friends if done after hours as well.  Having a structured telemedicine platform in place can communicate expectations to the client about when to expect a response or what to do in an emergency.  Such a telemedicine structure allows you freedom from your self-induced worry or guilt and it allows you to check the telemedicine consultations when you can focus your attention and time on them.  This can help avoid those fire-drill scenarios where everything requires immediate attention or response.  Finish working with your patients in the hospital and making your treatment plans, then check your non-urgent telemedicine consults.  You can be more efficient and worry less.  Most importantly, all the patients are being served.
Another strong benefit we have discovered is that a telemedicine platform provides better communication with the client.  No matter how excellent your support staff is, passing messages allows for misinterpretation or misunderstanding.  Instead of the owner relaying information to the receptionist or veterinary nurse and the passing of messages, you get the concerns directly from the client where you can also ask your own follow up questions.  This also eliminates the extra step of recording your medical notes as most platforms allow for a download of the consult directly to the medical record, thus, improved and more efficient charting.

So…. How to start?  How to transition?  How to retrain existing clients?
1. Simple, just start! Get your methods and/ or platform in place.

2. Send out marketing emails, social media posts and staple flyers to each receipt. It won’t be perfect on day one, but you & the clients will grow into it.

3. Start small to gain comfort.

How to suggest telemedicine to the client?
“Check out this new service we have!”

“It will put you directly in touch with your veterinarian, bypasses the reception desk and the passing of messages.”

“Hey, this really is a helpful tool because it allows us to document the conversation and recommendations to your pet’s record.  Nothing gets missed or forgotten in between visits.”

“Send me a picture of this lesion in 2 weeks via our telemedicine service. Hopefully we can save you some time.  You may not need to come for an in-office recheck as long as it is responding properly.”

“Hey, I’m not at the office. Let’s use this service so my staff can see our conversation and get the meds ready for you before I get back.”

“Dr. Johnson doesn’t have an opening for an in-office appointment until next week.  Did you know about our telemedicine service?  This sounds like something she might be able to address with that appointment type.  Let me send you the information to start a consult with her.”

What types of patients fit telemedicine?
1. Non-emergency. Your welcome message should clearly say, “A telemedicine consultation is not suited for emergency care.  Please call our office immediately for an emergency.”  We would also recommend that you give an expectation for your response time.  For example: “Your concern will be addressed by the end of the business day.”  Structure it to suit you.

2. Skin issues, first time ear infection after swimming, simple rechecks/ follow ups, post-surgery follow up, normal healthy dog with acute diarrhea, allergy consults, behavior consults, so many options….

Ask the client to share pictures or videos until you are satisfied in making an assessment.  If you still aren’t comfortable with making a determination, simply say, “Looks like Fluffy actually needs to come in for tests, treatments, etc.”

You can always provide your recommendation and leave off with, “Let me know if he is not showing improvement in 12-24 hours.  He may need to come in for further evaluation.”

What style of telemedicine will you perform?
1. Do you prefer the live conversation?  You can schedule times for video consults via a platform.

2. Must you perform video consults?  Only if you want to.  I predominantly utilize the messaging feature for communication.  Often, the clients’ availability is just as challenging to schedule around as mine and it seems most clients also prefer messaging.

Whether the patient is coughing, has a lameness or a behavior issue; the client usually needs a couple “takes” to send the best video.  It’s sometimes challenging to get the pet to “perform” in a live consult.

My response, “No problem.  Take your time and try to send me a couple videos that show me that right leg and also whole-body videos from the front and behind so I can see the whole pet while he is walking.”

Does this mean you are on call via telemedicine?  Only if you want to be.  I’m not.  My welcome message makes it clear this is not for emergencies and I’ll be in touch by the end of the next business day if it is after hours.  It also provides contact information for after hours emergency services.

How do you fit this into your already busy day?
I know! You don’t have any open appointment time!  How do you make time for this extra service?  It is way easier to fit a telemedicine consult into your day than one more appointment.  It is even easier than a drop off appointment once you’re used to it.   I found that once I got up to speed with the telemedicine platform, a lot of inefficiencies went away and time actually opened up.  The urgently pursued non-urgent questions started to disappear.  My staff is available and not juggling a pocket of notes and callbacks when I need them for something else.  If I handle all these consults as drop off appointments, I’m utilizing technician and receptionist time and adding to the treatment room to do list.  Usually I am handling the telemedicine consults in between my appointments when I have a spare moment.  I make it fit the day.  It doesn’t run the day.

What is an example scenario on how to handle telemedicine in your day?
I return to my desk to chart after an appointment and I see a notification that there is a telemedicine consultation waiting for me to address.  I finish my charting, then read the message. It’s about Ellie licking her feet all the time and she now has some sores. I respond, “Oh poor girl!  Has she ever done this before?  Can you send me some pictures of those sores?  And how would you rate her itching/ licking on a scale of 1-10?”  I hit send and run off to see my next several appointments.  Later I return to my desk and have some pictures in the message thread to review.  At this point, I am content with the information I have to make some recommendations.  I’ll provide some client education about allergies or insect bite hypersensitivity, or caustic irritation, or subcutaneous foreign body.  I’ll recommend a plan and then ask them to monitor for a variety of other symptoms that may change our course of treatment.  I may recommend an OTC option.  I may recommend a prescription for itching or an antibiotic option that they can come pick up at their convenience.  In this case, I recognize that a similar scenario happened exactly one year ago and the sores don’t appear to require an antibiotic at this time, so I recommend they come in for a Cytopoint injection with a technician.  Then with one click, I can request my front desk to schedule a technician appointment for Ellie for a Cytopoint injection.  I can still charge for my consultation at this time.  Ellie doesn’t need a doctor when she gets there.  My technician will perform and charge for the injection.  She will then recommend they follow up with me via telemedicine again if they have any further questions, if Ellie isn’t getting better and in two weeks with pictures as a recheck.  So, let’s say Ellie’s problem is more complex or the client has a hard time getting good pictures or video.  No reason you can’t change your mind in the middle of a consult. Simply message, “Ellie actually does need to come in for an exam.”  You can charge for the telemedicine consult and use it as a credit towards the in-office exam fee.  You are in charge of this service, this patient, and your license and you get to decide what you are comfortable with to make your diagnosis and treatment plans. Embrace telemedicine as a tool, not a new way of life.

How do the clients react?
The vast majority of clients like it and are grateful for the communication and care they have received over the telemedicine platform.  Overall, they like that they can send a message when they think of it in the evening on the couch, understanding that they won’t get a response right away.  They are grateful they don’t have to take off work for a simple issue and are still getting their pet care and comfort.  A few clients may have trouble getting started and need a little coaching, but even then they will probably like it once they have the first experience under their belt.  Very few have said they don’t like it. It’s just another tool to make your life simpler and it really is convenient for the client too.  The clients appreciate that they have a direct line to you.  But you get to set the times you are available, how quickly you respond, its saving to the patient record and you are getting compensated for your time.
Of course, your clients are still going to send emails.  They don’t know about your new service yet.  You can let your staff review the emails and respond at no charge, if that’s what you want to do.  For instance, they can give simple advice as they might over the phone or let them know that this problem does need the veterinarian’s attention.  If they think it needs a doctor, then they direct the client to the telemedicine service or schedule an appointment like usual as they triage the concern.

Like anything new, it will probably take a bit to get used to, but with a little diligence it can end up being a big timesaver.  No need to be intimidated.

Remember…
1. You are already doing telemedicine!

2. You can structure it to suit you!

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