Tennessee State Worker’s Compensation Conference
June 7, 2018
Good morning. My name is David Tutor. I’m an occupational health physician in private practice in Knoxville. I’m going to speak to you today from a provider’s perspective about the benefits of telemedicine in the treatment of injured workers.
I thought I’d open by sharing a brief – and I’ll apologize up front, anyone who knows me realizes brief is not in my vocabulary, but I’m going to try – background history of my practice to let you know how I’ve ended up here talking to you about this topic.
When I opened my current practice in 1996, it was a conventional “brick and mortar” practice. I ran into the same issues that most solo practitioners do. After a few years of high overhead/flat reimbursement, I ended up working for a hospital.
Well, I had already been there/done that with a hospital-based practice before and decided that wasn’t for me! Turns out I’m not a good employee. So about 12-15 years ago, I began to transition my practice to providing contract care in on-site clinics where the employers covered the cost of overhead. Fabulous idea, right? I thought I’d hit the lottery!
It was a valuable move. For more than 15 years I worked at on-site clinics with dedicated teams of occupational health nurses, mid-levels, physical therapists, athletic trainers, HR and EHS professionals who really understood the impact that work related injuries had on the life of the injured employee and the business. We were able to conceptualize and implement a results-driven model of injury evaluation, treatment and management that provided successful outcomes for injured workers and employers.
That’s what every employer should want, right? The answer seemed obvious to me – but cost constraints, geographic limitations and liability concerns all presented a significant problem for expansion of that program.
So, what does the typical 50-something year old physician do?
Before I answer that, let me provide a little background. In 1992 I completed an AMA survey indicating that I never anticipated needing or using a computer in my medical practice, ever! Now, in my defense, more than 70 percent of people who responded checked the same box!
So what do I do? Of course I turn to a computer and technology to solve that problem.
About three years ago, we – that being my current telemedicine team and I – began to conceptualize transitioning the practice yet again using the same treatment model with the same principals and protocol, but this time we applied them to a virtual, technology based telemedicine practice. Makes sense right? Now we’ve eliminated the conventional clinic constraints.
As for my conventional clinic – in early 2017, I successfully closed it!
Also In 2017, we worked with a healthcare-based, HIPPA compliant video platform provider and a healthcare-based, HIPPA compliant App developer to successfully roll out our HIPPA compliant (do you see the a recurring theme here?) Virtual Visit App through which we provide our occupational Telemedicine services. We can operate on all common commercially available operating systems and devices such as IPhones, Androids, IPads, Android tablets, and IOS and windows based laptops and PC’s.
In early 2018, we began on-site implementation of our program. Employer interest and employee acceptance of use has absolutely been phenomenal. Most importantly though, we’re seeing very successful injury outcomes that are on par with those that we see in our conventional onsite clinics.
So, what does this look like? What should you expect? How’s it work? Let’s talk about that:
24/7/365 virtual on-site clinic complete with RN’s, mid-levels, and physicians who provide face-to-face (video and audio), HIPPA compliant healthcare visits.
Injured workers have immediate access to APPROPRIATE worker’s comp care – regardless of time, date, or location.
The site needs:
- a good OCCUPATIONAL telemedicine provider,
- a device with camera, microphone and speaker,
- an internet connection
- a private area for the visit.
What’s the TAP TO TREAT process look like?
- Injury occurs
- Injured worker reports to employer per protocol
- Injured worker directed to facilitator (may be medical personnel or may be a manager – trained in use of the telemedicine system)
Note: If the injury requires emergency care, EMS is activated – but for the purposed of our discussion, we’re assuming the injury is telemedicine appropriate.
- The facilitator gets the injured employee to the telemedicine device
What’s a visit look like?
Other than not physically being in the same room with the patient – which isn’t as big a deal as it might seem – these visits are comparable to conventional clinic visits.
We obtain a comprehensive history to include history of the present injury (the where/when/why or date/time/place/incident). We include detailed documentation of current injury symptoms, any prior injury, condition or chronic symptoms in the affected body part or organ system. Other information includes: any outside work injury or activity that may be contributing to the current condition, past medical history, past symptom history, medication list, allergy history, and appropriate social and occupational history.
We perform comprehensive virtual physical exams that can assess blood pressure, pulse rate, pulse oxygen level, temperature, general appearance, pain level, mental/psychiatric status, eyes/nose/throat appearance along with skin and neuro-vascular status.
Our experienced occupational health professionals focus in on the affected body part with a detailed exam assessing for point tenderness, swelling, bruising, redness, heat, masses or knots, range of motion, as well as bone/joint deformities, instability, or spasms. We assess gait, balance, coordination as well as perform other assessments as the injury may dictate.
We have access to mobile diagnostic imaging for on-site X-rays (depending on location) plus partnerships with local diagnostic centers and physical therapy providers when needed.
All this detailed evaluation allows us to arrive at an accurate diagnosis in order that we can recommend an appropriate treatment regimen (including return to work guidelines). We then follow the patient virtually throughout recovery to all the way to maximum medical improvement (MMI). It’s that simple!
Of course, not all injuries/conditions are appropriate for virtual care. For these we maintain strategic partnerships with local occupational medicine and specialty physicians when the injury requires their services.
What about the paperwork?
We can complete any necessary paperwork virtually as well – all completed interactively by/with the employee.
- Appropriate state mandated forms
- Worker’s compensation questionnaire for the employee to state in their own words what happened
- Return to work guidelines form
- Worker’s compensation injury instruction sheet
- Any custom forms the employer may request
At the very beginning of the detailed exam described above, the RN triages the injured worker in order to determine their path forward. The levels of triage are:
- No treatment (such as with a precautionary visit)
- Simple first-aid (which the employee can perform per self, or with assistance of the facilitator or an on-site medical person such as an EMT)
- Escalation to TAP TO TREAT mid-level provider and/or physician
- Escalation to off-site clinic (such as if employee needs stitches)
- Activation of EMS for emergencies
We practice “Injury to MMI” case engagement with our occupational health professionals who follow the injured employee from the moment the injury occurs throughout treatment until MMI.
- As the authorized treating physician when medically appropriate and accepted by the employee – enabling care from injury to MMI to be provided virtually. This eliminates the need for the employee to visit a conventional clinic – which is our goal.
- Case management when injury requires or the employee chooses conventional clinic care.
What this means: anyone who’s using this product simply for afterhours triage to capture patients for their conventional clinics is far under performing with the technology….
The injury to MMI practice philosophy provides – and this is very important – a Single Point of Contact (the same nurse who performs the initial triage stays with the employee from injury to MMI) for communication with the employee, employer, insurance adjuster, case manager and other stakeholders for comprehensive injury updates.
SLIDE 6 & 7:
Unfortunately, employees may be sent to an emergency room as a “knee jerk” reaction to an injury – even if the injury is minor. In addition to putting an additional burden on an already overwhelmed emergency system, the expensive emergency department visit also often causes a non-recordable injury to become needlessly recordable.
By utilizing TAP TO TREAT’s services, the employer can:
- Save the ED charge
- Avoid “obligatory” prescriptions
- Avoid “obligatory” restricted days and lost time
- Avoid potential for unnecessary testing and referrals
- Avoid transportation issues
- Avoid the inconvenience and lost productivity of waiting
- Avoid exposures to infectious illness and other ED “situations”
- Avoid communication gaps
The results of our virtual face-to-face evaluation and treatment are often very similar to those of walk-in/urgent care clinics.
SLIDE 9: Our 24/7/365 availability for the evaluation and treatment of work injuries can eliminate unnecessary Emergency Department and Walk-In Clinic visits – saving money and time for employers.
SLIDES 10 & 11: To recap/summarize—some of these we’ve already addressed, but they are worth repeating – benefits of TAP TO TREAT includes:
- Early intervention with immediate evaluation/treatment for their injury
- Convenience—first visit “onsite”, follow up “wherever they’re comfortable”
- Avoid travel, wait times and “the flu”
- One point of contact—RN is with them from injury to MMI
- Daily healthcare visits in the acute injury phase
- Avoid unnecessary testing, meds and referrals
- Financial–avoiding lost time + remaining engaged, satisfied and productive
What’s one of the most (if not THE most) important benefits of providing patient care via a computer monitor in Worker’s Compensation? COST SAVINGS!
Virtual care can be provided for a fraction of the cost of conventional clinic care.
Now we can have Telemedicine and the benefits that come with it available to more sites – that means more employees getting better care. That’s exciting! Sites that couldn’t afford on-site care before now can, while sites with conventional clinics can enjoy support for on-site providers.
In either case, employers recognize a program that is going to provide their employees (and them!) with better outcomes and cost savings. Talking about a win/win!
So what’s my take as the provider on all of this?
Well, for a guy who’s spent the better part of his professional career conceptualizing, molding, fine-tuning and implementing this program in medical practice—to see it come together in a product that can positively impact so many employees and employers on a scale that 5 years ago would have been at best improbable—well, I consider that a pretty good day at the office.