Telemedicine has been around for years, but only recently has it become more widely accepted and adopted by both the medical community and patients.
The surge in interest has in no small part been due to the Coronavirus pandemic, which forced thousands of healthcare professionals to seek virtual care options in order to care for their patients while mitigating the spread of the virus.
While many physicians and providers scrambled to find a telehealth solution, it didn’t take long before many were asking themselves how they might be able to start their own telemedicine practice not only in an emergency situation but for everyday use.
Initially, the answer seems rather simple -- just find a HIPPA-compliant video chat platform and integrate it with an electronic health record (EHR) and then start seeing patients.
Well, once one digs a little deeper, it becomes quite apparent that creating an independent telemedicine practice is a much more complicated endeavor.
Here is a list of things to consider when starting your own virtual medical practice:
The Website
- Domain Name (godaddy, namecheap, google domains, others)
- Hosting (siteground, hostgator, others)
- Content Management System (WordPress most popular and best for SEO)
- “All-in-one” options (Wix, Squarespace, others)
- Decent templates, easier for user, but less control over the details and SEO
- The website is the most important asset for bringing in leads, new patients, and informing the world about what you offer. I prefer WordPress with a theme like Divi, but there are several themes out there.
- Plug-ins for WordPress: email/security, forms (e.g. Gravity), booking (vcita, calendly, others)
The EHR
- Most are tailored for brick/mortar and insurance-based practices
- Many to choose from - PracticeFusion, Elation, Atlas, eClinicalWorks, Charm, and others
- Have to ask yourself -- who is going to enter the patient info into the system? Do you want it automated? Will your EHR allow new patients to enter their demographics and medical history on their own, or via a portal/link on your website? Redundant data entry gets old fast.
Payment Processor
- Stripe recently put telemedicine into their restricted industries (alongside sin industries like gambling/cannabis, adult sites, etc), however many healthcare entities use Stripe on the back end...so the jury is out regarding whether or not they will enforce this
- Alternatives include bank merchant acct (they may steer clear of telehealth/internet as well), Paypal, payment cloud, and a few others
Membership Management
- WordPress has some plug-ins like S2Member (I used this but it was fairly complex to set up) and many others. They will link to Stripe/Paypal, etc.
- Hint.com is robust but a little much for telehealth alone..and expensive
- Manually keeping track -- labor-intensive
- IntakeQ and other software has membership management built into it
- Does it integrate with your EHR, payment processor, a communication platform, etc.? Again, you want to avoid duplicating work/data entry
Booking Calendar
- Many stand-alone options (Calendly, booklikeaboss, etc.)-but do they share info w/ your EHR, and are they HIPPA compliant?
- Some EHR’s have online booking. Just need to add the links to your website for active members/patients
Fax / Document Management
- Many stand-alone options (Updox, Doximity, efax, humblefax)
- Some integrated into EHRs
- Ask -- do you have to have a cloud document service as well like Dropbox or Box or Google Drive? If so, you have to move documents, rename, etc from one system to the other.
Portal / e-communications
- Built into EHR or separate?
- Hippa-compliant messaging like Spruce is great if you have a team to help --their group messaging is amazing and they have built-in fax and video conferencing. It is a little expensive but very easy. They integrate with some EHRs
- Email and Text alone via your phone may cause privacy issues. Are those messages automatically put into the patient’s chart? Or do you have to copy/paste? Having communication be automatically part of the record is key and saves you from having to cut/paste or re-enter info into the EHR
- Patients want the least friction to communicate with you. They don’t like to download a separate app
Video
- Probably over-emphasized when it comes to telehealth. Most people prefer asynchronous messaging rather than video
- Doxy.me, Zoom, GoogleMeet, Skype, etc are all inexpensive options -- just add a link to your website or portal for them to click at the time of appt. Consider HIPPA-compliant options...but most video isn’t stored anywhere (nor shared) so this may be less of an issue. The most important thing is that it works on multiple devices and again, people don’t want to download another app. Not everyone has facetime (e.g. Android users)
Marketing
- To make money, you’ll have to market, especially if you are not billing insurance.
- Paid ads are expensive unless you know what you are doing and are only practicing in a narrow geographic area without much competition
- Content marketing (blog/articles) is time-consuming but pays off over the long term
- Social media is also time-consuming and needs to be highly targeted and it’s hard to keep up with the latest unless you know what you are doing
Legal
- Healthcare attorneys are VERY expensive. I paid >$500/hr for legal services, including agreements, privacy stuff, Medicare compliance, etc. There are templates out there, but you may have a unique situation. The biggest things to worry about are anti-kickback/Stark, and Medicare/Medicaid compliance. Terms/conditions, privacy, and patient agreements can be hashed out but go to the lawyer with specifics...otherwise, it’s a lot of back and forth
Licensures
- The more states, the higher likelihood of growing faster
- Each state has different regulations/requirements
- The Interstate Medical Licensure Compact is popular
- Some states are easy, like the Florida Telehealth license.
- CA, TX, and FL are the most populated and popular, but it really depends on what kind of market you are seeking to attract
- Politically liberal/democrat states tend to have more restrictions on direct care/self-pay practices.
Prescribing
- eRx usually included with EHR
- Stand-alone apps like iPrescribe are ok, just think about having to enter patient info each time. Best if they sync with your patient list
- Controlled Meds generally a no-go for telehealth
- Faxed prescriptions phasing out
- Think about refill request workflow -- from pharmacy vs. directing patient to doctor for requests?
Documenting Care
- If direct pay, non-insurance -- this is simple -- just need a basic note or SOAP note
- If insurance --then go with an EHR that has more robust notes and templates
- Template, text-expanders, macros -- helpful
- Dictation - most voice-recognition built into browsers (Siri, Google, Windows) work “ok”. Dragon and others for medical are good for longer notes but $$
Other things to consider:
Google Workspace (formerly G Suite) - keeps everything in one space and has a BAA.
Zapier to connect apps like Google Drive with intake forms and payment processors to do analytics and tracking.
Accounting: Quickbooks, Wave app, Xero, Spreadsheets
Corporation: PLLC, PC, tax as S-Corp; LegalZoom vs.? , minutes/meetings
Virtual Office: need an address for correspondence and outgoing on your prescriptions/referrals
Virtual Medical Assistants: Upwork, HelloRache, many others. Overseas VMA’s are cheap but language and oversight is tough
Virtual Receptionist: Davinci, several others
I, myself, took the leap into telemedicine back in 2013 when there were a few companies doing it, but the care seemed rather superficial and more like triage and one-off urgent care type of visits. As a board-certified family medicine physician, this just didn’t seem professionally fulfilling. I also noticed an increased interest in direct pay care, partly due to ever-increasing insurance deductibles and insurance hassles when it came to getting care. Why not merge the two -- telemedicine and direct care? So I decided to piece together a minimal viable product with my self-taught web development skills and years of experience at the point-of-care, treating patients in a busy primary care practice.
Around 2018 I started to develop an “all-in-one” product, CirrusMED.com, to cover most of the things described above and allow other doctors to utilize it. What first started as primary care only, evolved into multiple specialties as the pandemic led to increased interest from specialists. So now the platform allows patients to retain not only primary care docs, but specialists -- AND they can communicate with both via group chat (e.g. ortho and PCP on the same chat as the patient).
For me, the formula for achieving Professional Satisfaction = Continuity of care + Simplicity (EHR designed for patient care, not insurance billing) + Autonomy (control over pricing, schedule, and care) + Revenue (recurring/membership vs. the encounter trap which leads to burnout).
Creating your own virtual practice is one way to achieve professional satisfaction. While it can be achieved with proper planning and due diligence, there are platforms like CirrusMED.com which can help physicians get the ball rolling quicker.
Christopher C. Highley D.O.
Founder, Cirrus Medical Network