Telemedicine: Considerations for Documentation and Medical Records

Telemedicine Documentation and Medical Records Excelas Medical Legal Solutions

The rapidly growing telemedicine industry is on track to transform the way healthcare is delivered. With new technologies generating large amounts of patient data across multiple platforms, there is a direct impact to health information management and documentation.

What is Telemedicine?

Telemedicine, or telehealth, is a means to connect patients to health care services and education remotely through technologies like the internet, videoconferencing, streaming media, and wireless communications.  According to the American Telemedicine Association (ATA), telemedicine encompasses, but is not limited to, the following:

  • Live videoconferencing: a two-way, real-time interaction between a patient and provider in order to treat common illnesses.
  • Store and forward: the electronic transmission of recorded clinical information for evaluation purposes, typically among medical professionals.
  • Remote patient monitoring (RPM): the electronic transfer of a patient’s medical data from one location to health care professionals in another location.
  • Mobile health (mHealth): the use of smartphones, tablets, and wearables to support the prevention and treatment of health issues as well as boost patient engagement and empowerment.

While one form or another of telemedicine has been around since the 1950s1, it is now the fastest growing alternative care setting. It’s recognized by individuals, companies, and even the government as a way to further modernize healthcare. For example, in 2018, President Trump signed a bill expanding Medicare coverage of opioid-specific telemedicine services. In October 2019, he signed an executive order pushing for Medicare to adopt more telehealth programs.

The Continuing Demand for Telemedicine

Consumers want convenient access to healthcare that will save them time and money. They also want information that will help them make informed decisions. Smart phone applications are one way consumers use telemedicine to track their personal health. Some popular apps include:

  • iPhone Health: allows patients to securely store their health records from multiple institutions
  • Fitbit: allows tracking and sharing of certain health data with care providers
  • The Diary: lets patients work with their care team to track the efficacy of treatment and care plans

Physicians want to efficiently provide the best care to patients, while healthcare facilities aim to keep an eye on cost savings. Telemedicine helps rural hospitals improve patient access to specialized care, allowing them to receive video consults while staying close to home. Many skilled nursing facilities are using virtual, 24/7 physician services to reduce hospitalizations by providing timely care. Cleveland Clinic has built telemedicine into their growth strategy, projecting that 50% of outpatient visits will be virtual in just five years.

Even insurers are working to reduce costs to subscribers with convenient, easy-to-use digital tools. Many offer mobile apps that facilitate communication between patients and doctors. Anthem recently launched CareSpree, where users talk directly to doctors and use real-time data to analyze symptoms for potential diagnosis. UnitedHealth’s Recover app allows patients to take pictures of their surgical sites that are first analyzed using the Recover technology which then automatically alerts the surgeon to any problem.

Telemedicine Liability Concerns

As the number of patients using telemedicine grows, we are likely to see an increase in telemedicine-related claims. However, a virtual office visit or use of mobile health apps doesn’t necessarily carry a greater risk. Physicians must follow the same standard of care and rules for documentation whether or not they meet patients in person. And telemedicine platforms and programs must meet all HIPAA requirements and comply with security guidelines.

From a documentation standpoint, there are challenges related to the high volume of data generated by telemedicine from a wide variety of sources outside the traditional healthcare setting. Digital images, email, live streaming videos, and other data streams related to medical decision-making and treatment will be part of the medical record. At this time, the integration of mobile health apps with electronic health record systems is still a work in progress, but will inevitably need to be included as well.

As the evolution of healthcare barrels forward, Excelas will keep on top of any changes or challenges related to medical record documentation. To ensure you have all the medical facts needed to review your case, contact Excelas today.


1 Telemedicine: A guide to Assessing Telecommunication in Healthcare

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