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Telemedicine Workflow For Physicians

For physicians who are interested in doing telemedicine this post will give you a little insight into how telemedicine works; I’ll share with you my telemedicine workflow for this particular telemedicine company. I wish I could tell you which telemedicine company I’m writing about but they have contacted me and asked me to remove their name from my blog.

Another thing I like about them is that it’s not all cold and flu even though we are in cold and flu season. I’m sure it has to do with how this telemedicine company markets to consumers.

 

Telemedicine Workflow

I signed on as a per diem which means that I can log whenever I want and see patients for however long I want.

This flexibility is incredibly helpful and one of the best parts about Company X. There are no shifts and no time commitments.

There are both scheduled appointments and patients who are in queue for the next available doctor. There are mostly telephone visits and a few video visits which most providers try to avoid.

Accepting A Patient

I log on to the website, I click ‘lock’ and the next available patient pops up. This then becomes my patient until I end the visit.

Alternatively, physicians can log on and lock onto a patient who is requesting an appointment for later in the day or even the next day.

Telephone vs Video

Telephone visits are popular with the doctors because those are snagged up right away.

When you clock in, you can clock in for both video and telephone or just telephone. It’s obvious that most doctors have no desire to do the video visits – those just pile up.

I discussed in previous posts that live video visits are likely not the future wave of telemedicine. Recorded video and image sharing might be – but live video is clunky, time-consuming, and serves no clinical purpose.

Patient Volume

With OR, WA, and CA, there are more than enough patients during the busy months. I haven’t been with Company X long enough to know what the summer volumes are like – but I always have the option of getting credentialed in another state.

During the mornings and nights, there are often 3-10 patients waiting in the queue.

It takes me on average 5.5 minutes per patient. The longest visit was 25 minutes with a guy who was taking notes and that was my mistake for letting it drag out that long.

My shortest visits are in the 2.5 minute range – often for medication refill requests.

Prescribing Medications

The Company X software has an integrated prescription window. No need to call the pharmacy, no need to open a separate software – it’s really intuitive and one of the best ones I’ve used so far.

You can create a QuickRx for yourself for the most frequent meds you prescribe which will populate your directions and preferred dosages.

Technology

Company X has one of the easiest platforms for physicians to navigate and is quite reliable.

They have an iPhone app as well if you prefer to do everything from your phone. I have used this quite a bit and it’s very functional.

Since most of the consults are by telephone it’s quite easy to talk to the patient on the phone and simultaneously take notes on your laptop and even check on medications or diseases on Up-To-Date.

The video platform goes to an external website and it’s probably the least efficient platform I’ve ever come across. The video is odd because sometimes the patient has to be on their phone to hear the audio, the transmission quality is too low to see any details, and the prescribing software is nearly impossible to navigate.

 

The Patients

In order of the most frequent complains, this is what I deal with on Company X:

  1. Acute sinusitis
  2. Cold and flu
  3. UTI
  4. Vaginal candidiasis
  5. Muscle strain
  6. Fever in children
  7. Rashes
  8. Medication refill request

I find the patients on Company X to be quite easy-going and though most want antibiotics, I don’t think it’s any different from what I see in an office or on other platforms.

Patients are surprisingly open to conservative management but that’s really only the case with my WA and OR patients. The CA patients aren’t quite that simple.

Patients are offered this telemedicine service part of their insurance package and seem to love it. I’m still seeing a lot of patients who are using this service for the very first time but there are quite a few who have been using it since 2010 – that’s impressive.

I get no drug seekers. No opioid seekers. No benzo seekers. No Viagra seekers. No work note seekers. This telemedicine company must do a very good job at screening such patients so that they don’t end up on my schedule.

 

Credentialing as a Per Diem

I’ve written about the interview process with this particular telemedicine company and the credentialing process was just as painless.

It only took a few weeks but their email communication was a bit inefficient. Apparently I had to reply to one of the emails I received to confirmed that I had received it in order to gain online access.

2 months later, after looking through my emails, I discovered this email, replied, and got access the next day.

 

Company X Support

There are a lot of emails and text messages where Company X support will ask you to help out. I don’t want to say that this is annoying because the team is doing their part to get patients seen and if you’re in it for the money then it can’t hurt to be told about possible opportunities.

Patient related issues are handled quickly but inefficiently.

The 2 times that I reached out to Company X for help, the intervention that was offered was ineffective or counterproductive. One time the patient’s prescription never got sent in and the other time the patient I called wasn’t available and needed to be rescheduled.

Provider Relations

There is an email where you can contact provider relations for provider related issues.

I emailed them one time to let them know that one of the states I was licensed in wasn’t listed and if they needed the help I’d be happy to see patients from that state as well. 1 hour later that state was added to my profile and I received an email confirmation.

The second email I sent was to inquire when providers are paid and how we can check to make sure that we are paid correctly for the number of patients we see. That email went out 4 days ago and I still haven’t received a reply.

 

My Workflow

Here is a brief summary of my workflow and I’ll lay it out in more detail in the following paragraphs:

  1. setup my laptop, phone, bluetooth headset
  2. open the telemedicine window, pre-populated Google Docs window, and a Google Docs dictation window
  3. lock onto the next available consult
  4. talk with the patient as I take notes in Google Docs
  5. dictate my note into GDocs, cut and paste
  6. order medications
  7. close encounter and lock onto the next consult

Timing My Shifts

I have picked 2 peak times to handle telemedicine calls with this particular company – in the morning when I wake up and at night before I go to bed. There is a peak at around 8am PST and again around 9pm.

I am licensed in 3 West Coast states which gives me more than enough consults to do no matter when I log on.

My Technology

I have my $800 MacBook in front of me with the Chrome Browser opened on Company X. I have my cell phone connected by bluetooth to my $500 headset and I dial *67 and the number that comes up for the patient and begin.

In the future, I’d use a background noise-cancelling headset that’s wired. These can be purchased for less than $100.

Confirm the patient

I first have the patient confirm their state and DOB which is 99% of the time accurate. If not, I cancel the visit and have them contact customer service.

To confirm the patient I click through a few questions confirming that I confirmed all the important data (I love this idea). And then I get taken to the C.C. and Symptoms screen.

Most of the time I don’t know why the patient called so in order to not waste time fumbling for a CC or Sxs which won’t populate in their dinky search, I open Google Documents and take notes as the patient talks.

Google Documents Dictation

Google Docs is your best friend. I have a screen open with pre-printed “physical exam” stuff and I have another Docs screen open where I free-type everything and later dictate off of my notes.

When the patient is talking I just free type. Because GDocs has a feature to auto-correct, I am much more efficient at typing the patient information into that window instead of the tiny little screen on Company X.

After I hang up with the patient I dictate my ‘Plan’ and I can tell you that GDocs will blow Dragon Speak out of the water in terms of its efficiency.

Then I highlight my text, cut, paste and I’m done.

Prescribing

I’ll talk more about how awesome their Rx software is. It’s native in Company X so you don’t have to use a separate software.

Both OTC and Rx meds are on there and many things come with the proper dosing and frequency populated which is a big time saver.

I have a saved list of common meds which I prescribe: Tamiflu, Diflucan, Meloxicam, Macrobid, Tessalon, Triamcinolone, Amoxicillin, Doxycycline, Bactroban, Baclofen. 

 

The Income

Update: This telemedicine company sneakily baited me with a $28.50 per-patient income offer letter and after reviewed the many documents I signed there is a part that states I get paid $23/patient for telephone visits and $28.50 for video. I won’t update the numbers in this post but I’ll add that at $23/patient wouldn’t be competitive enough and I would turn to JustAnswer and another telemedicine company (whose name I also can’t mention) for more lucrative options. 

As a per diem clinician I get paid $28.50 ($23?) per consult. I have no idea how often and on what dates the paychecks come because this information isn’t available on their website nor have I been able to obtain this information from provider relations.

The first direct deposit I received was on a Tuesday on the 16th of the month. I got paid $953.00 which doesn’t make sense with a patient payout of $28.50 per patient.

I am fairly certain that the income is a 1099-MISC for independent contractor work but hopefully I’ll know for sure once I can get in touch with the right people.

It’s easy earning a solid living doing telemedicine as I’ve written in this other post. 

Patients Per Hour

It wouldn’t be wise to shoo the patient off the phone but efficiency matters because you are paid per patient you see. Which is why I complain about having to waste a couple of minutes on finding the right words to fill in the autopopulating fields.

I can see somewhere around 7-10 patients per hour which comes out to $199.50-$285/hour.

The reason I’m able to have a higher volume is because I don’t waste excess time on patient verification issues, I move through the software quickly, and I dictate. It’s also important to provide as much information to the patient as possible – this decreases the number of questions they will have and moves the conversation along faster.

If you’re willing to put in 2.5 hours a day then it should be fairly possible to see 20 patients in that amount of time – that’s $570 of gross income per day or $16,000/month.

 

My Gripes With This Telemedicine Company

Empty Calls

There are a lot of calls where the patient doesn’t pick up the phone.

Company X wants you to leave a VM so you have to wait for the rings, wait for the greeting, and then either leave a VM or find out that they don’t have their mailbox setup or that their mailbox is full.

You don’t get paid for these empty calls.

No Chief Complaint

When you click on a patient there is often no information as to why they are being seen which slows down the documentation.

It’s smart, however, because they don’t want doctors picking and choosing. You don’t see the gender, age, and often don’t see the CC.

No Live Image Sharing

Once you begin the call with a patient there is no way for them to upload images. So if I ask for a picture of a part of their body that they are talking about then I have to cancel the visit and have them submit a new consult and upload images.

CC and Sxs

The Chief Complaint and Symptoms fields need to auto-populate – no free typing text.

I think the CC can be written in if you select “Other” but the Sxs has to autopopulate which is really tough because I can’t read the computer’s mind.

Diagnosis

Even worse than CC and Sxs is the diagnosis field which of course has to be from a list of ICD-10 diseases. There is a search function you can use but that opens another window and isn’t much better than the native Company X search.

This is a common issue with any new platform and fairly easy to get used to especially since the same complaints pop up.

My Praises

Patient Volumes

The volume of patients is solid. I haven’t had to waste time being online without any patients which was a big problem with American Well.

Friendly/Easy Patients

I really enjoy the caliber of patients who come online. They are grateful, they have simple complaints and generally quite agreeable.

Difficult patients or those who don’t know what to expect will slow down the workflow. Hopefully this company will continue to do a great job of filtering patients.

Intuitive Prescribing

I love, love, love the Company X prescribing window. It’s so easy to select the right medication and often the right dosing and frequency is also filled in. This makes it incredibly efficient to make it through the workflow.

Solid Phone App

The phone app is shockingly well designed and really helps in an efficient telemedicine workflow. I am not sure how big this telemedicine company is but man, they have their softwares down!

 

10 replies on “Telemedicine Workflow For Physicians”

I have commented previously and think I am on a similar path as you, though you are just a few year ahead. I work urgent care and just was recently credentialed with this company so this is a timely review. I have not started seeing patients yet as I am waiting to hear back from them about a few concerns I have.

I also have multiple state licenses but only 1 DEA number. I spoke to someone from recruiting and they said multiple DEA’s are not needed, only one valid DEA is required for telemedicine, can you comment on this given you also see patients in multiple states?

Do you feel it is easy or feasible to keep up the pace of 7-10 pts an hour for several hours and are there enough pts in the que to keep up with your pace so you would not be sitting and wasting time?
I am excited about the prospect of a side gig but am concerned about wasting time waiting for the next pt or being able to keep a sufficient pace to make it worth my while or should I just pick up a extra shift in the UC.

How do you determine to prescribe abx? Is there some standard guidelines to follow so you keep with standard of care. How do you prescribe abx for UTI with no exam or UA, what about earache or conjunctivitis?

Also, the pay structure is different for video and phone visit. I believe as you stated the pay is $30 but that is for a video consult only, phone consults pay $20. Maybe that is why your check was not what you were expecting.

Anyway thanks for your valuable input, I read all your post as I feel they are very relevant to my situation.

I have one DEA and it hasn’t been an issue.

Depends on what you mean by several hours. Also, how many state licenses do you have? Which telemedicine company or companies are you working with?

If I work with 2-3 companies and I have multiple state licenses then it should be easy to see 7-10 patients per hour for 8 hours a day. Also, focus on high-volume times which seem to be morning hours, evenings after work and again at 8-10pm.

I don’t know many doctors who can maintain a pace of 7-10 patients per hour and definitely not for several hours a day. I can do it and I think you can definitely maintain that but if you want to do it for 8 hours a day I would worry that it might burn you out.

My trick is I log on and when it’s slow I log off. I take notes of when it was busy on log on the next time on that same time-slot. Right now I’m on Company X and there are 16 patients waiting to be seen – I saw 4 and now there are 9. So it seems there is plenty to go around. I can also call my scheduler at DoD and hop on their schedule or log onto Spring or JustAnswer – again, it’s about the strategy you use and your realistic speed.

I saw 29 patients today on Company X. I did 15 in the morning with my coffee for about 2 hours and I did another 1.5 hours in the late afternoon. Financially, that’s a decent amount. Volume-wise, it’s a lot of patients.

I think that topic of when to Rx abx is too broad of a question for me to address here in the comment section effectively. You have to follow community standards. If doctors in your community treat a UTI on the phone then you can do so as well.

Example, if a 35 yo monogamous woman has blood in the urine, urgency, frequency, hesitancy, mild abdomen pains and she doesn’t believe she is pregnant then it’s a UTI – that’s how I treat it.
Someone with pus on their tonsils, low grade fever and congestion and cough has a viral pharyngitis – otc meds should suffice.

I’ll have to follow up with the pay structure. I’m 99% sure that it’s $28.50 for all visits since that’s what my contract says. If I don’t get that then I’ll certainly hold them to the contract they signed with me.

I currently have 2 state licenses and just finished getting credentialed with them.
I also looked at doing Doctors on Demand but think I will give Teladoc a try first and see how I like it.

I would like to cut back a shift or 2 in UC and was hoping to supplement the lost money from doing less shifts in the UC by doing some telemedicine. Of course I will need to give it a try for a while to see if it is something I enjoy and if I can keep busy enough on a regular basis to replace some of my lost income from UC.

I know my contact with them is $20 per phone consult and $30 per video consult so maybe it is different from state to state depending on the needs. I do know when I spoke to Doctors on Demand they did quote $28.50 per patient but I never went further than the first interview.

I thought this was a great post and I will definitely be incorporating some of your recommendations into my workflow to be as efficient and productive as we are paid per patient.

Somehow they must have snuck that price deal past me. My initial contract says closer to $30. Videos are a bit too tedious to make it worthwhile.
Interestingly at the low $20-price-point JustAnswer might be more worthwhile because there is no diagnosing anyone and no prescribing medications.
I’ll report back. I’m pretty sure DOD is still $30 per consult. I’ll have to double check now.
Thanks for pointing this out.

Hi! Thanks for the info. I am a family medicine physician and recently signed up for JustAnswer. However, the company has not contacted me to tell me I have been approved and it has been over two months. Any advice?

I would continue to contact them. The demand is high and the physicians who are approved tend to do a couple of answers and rarely continue. There is plenty of work to be had but JA might be reluctant to add in doctors who won’t stay on. I would contact them and let them know what your actual intentions and availabilities are, that wouldn’t hurt.

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