How to Get Started

Telemedicine Training | Tele Health Services

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In order to begin doing telemedicine, there are some preliminary steps to take. As with anything worth doing, the advance preparation will result in a much better final product. You will be committing time and money by adding telemedicine to your practice; the advance preparation can help you have a better return on your investment and possibly increase patient satisfaction

It’s important to:

Research: You will be less likely to overspend or purchase equipment you don’t need or can’t use. 

Estimate: You should have a realistic estimate of how much time you and your associates can devote to telemedicine.

Locate: Where will the equipment be placed? How do you expect to get a return on your investment?

Investigate: What are industry “best practices” for workflow? What procedures are reimbursed (or not reimbursed)?

Gauge Interest: Have you considered an informal assessment of patients’ feelings about telemedicine? Many patients appreciate the convenience of telemedicine. Others may prefer in-person visits. Is this due to unfamiliarity with telemedicine? Patient acceptance of telemedicine practices is often improved by good communication in advance.

Set Expectations: Make sure everyone understands how his/her job may be affected. Are they willing to adjust and support the technology?


Starting Point
Not knowing your level of expertise, we’ll begin with some basic suggestions and pose a number of questions for you to answer.
Draw up a plan:

How do you expect the telemedicine program to tie into your regular in-person practice?

Are you planning to extend your practice and open satellite offices staffed by mid-level providers?

What type of clinic hours will you devote to telemedicine? 

What time could you save by implementing telemedicine?

How will your telemedicine program be used?

a. Primary care consults?
b. Specialist consults? 
c. Mental Health? 
d. Tele-ICU?
e. Emergency Department use? (such as Tele-stroke) f. Pediatrics?
g. Pathology? 
h. Tele-pharmacy?
i. What specific tests or assays are needed for the consults?

All of these utilize telemedicine equipment. Systems can be designed to work with a variety of specialties, but the solution is typically designed to focus on one essential area of interest.

Will your equipment work with:
- An existing hospital system where you have privileges (or hope to have privileges)?
- The existing “legacy” equipment?
- New equipment or networks that are installed/upgraded?
- Will it easily integrate visible light images with a health information system or a PACS (picture archiving communication system)?

Will the equipment you use be:
- The hub of the telemedicine practice? In other words, the central contact point for videoconferences.
- Used to videoconference with some other central location? The hub will usually determine whether the video connection is hardware- or software-based.
- In your office or clinic? Will you want the ability to connect to the system from your home and videoconference from there? These are all important considerations to understand at the beginning.

Some physicians are the technology “champions” of their practice. They were the first to integrate tablet computers with EMRs, the first to get a “smart” phone, and now they may have an iPad™. Working with new technical devices comes easy to them. But even if you just recently got around to setting up your first email account, you can learn what you need to know about telemedicine equipment fairly quickly.

Here are some initial suggestions:

- Look for systems that are intuitive. Are there controls for hardware and/or software? Does the location of the controls make sense and are they easy to use from the get-go?

- Check which systems are ergonomic in design because if you and your associates are comfortable using them, your patients will be comfortable.

- Ideally, you want equipment that is ready to go out of the box. How clear is the user manual? If the “getting started” manual is more than a few pages long, you may not be able to begin using it immediately.

- How will your equipment arrive at your office? In pieces, with assembly required? A few companies offer “white glove” service, delivering the product to your door, fully-assembled, functional and ready to plug in for use.

Your Telemedicine Solution
Most people begin with a basic system and/or work with a telemedicine design firm to help them determine what they need for their practices. Systems vary because uses vary. A tele-stroke practice, for example, can be a simpler telemedicine design than one for an Ear-Nose-and-Throat practice that may require scopes, cameras, and an illumination device.

Your Telemedicine Solution
Identify the kind of equipment you will need for your telemedicine practice:
Do-it-yourselfers can purchase and assemble individual items. Here’s a situation where a checklist would be helpful.

- Monitors: What do you want to see? What size would work best? How many do you need?

- Computers: What connections do they have? What is the operating system?

- Microphones: Echo-cancelling, omni-directional or uni-directional?

- Image Automation Software that captures and stores images, sometimes referred to as “Store and Forward.” These are “visible light images” (as opposed to non- visible light images, such as x-rays, etc.).

- Does the work surface need to be resistant to germs and/or contamination? (This is a consideration for patient safety.)

- Video camera(s), HIPAA compliant videoconferencing software or network hardware (called a CODEC), examination camera(s), cables, other peripherals, even desk or office furniture.

Continuity: Integrated, standardized equipment will lead to easier rollouts, training and support. Only those who really know what they are doing should buy used equipment. You may pay less on the front end, but integrated equipment will save you money in the long run. (And you won’t have cables running here and there which makes it look like you did put it together yourself.)

You may choose to buy a system off the shelf from a qualified and experienced vendor. Buying off the shelf may seem more attractive, especially if a custom order might take weeks or months for delivery. But will the off-the-shelf system be exactly what you need now? And ask the vendor if such a system is expandable for future growth.

You can purchase a scalable system designed specifically for your practice. The advantage of this option is the equipment suits your practice, and may have the greatest flexibility for future growth. Make sure that if you buy Version 1.0 today, however, the company still intends to support it when it rolls out Version 2.0. Also, make sure that the equipment, both hardware and software, works with your current computer system. (For example, some equipment now works with Windows 7, but many still require Windows XP or Windows 2000.)

Your Telemedicine Solution – PEACE OF MIND. Whichever route you choose, there are factors to consider, both during and after the purchase.

- Does the equipment have the FCC Class A and CE Marks?

- Is the equipment designed with an IEC 60601-1-2 “Medical Electrical Equipment” product standard?

- Does the equipment support the DICOM 3.0 Imaging Standard and was it conformed with the DoD/
VA VistA PACS Standard? - Has the equipment passed the rigorous Canadian Standards Association (CSA) testing. (This is
especially important when working internationally and making sure the equipment is cleared for sale in European and some Asian countries.)

- What is the quality policy of the manufacturer?

- What industry affiliations does the vendor or solution provider have?

- Are they affiliated with any telemedicine organizations?

- Are they affiliated with a manufacturer or development team?

Interoperablity Standards: 
- Is the equipment or software validated to work with your current configuration or setup?

- Manufacturer interoperability?

- What recognized standards (DICOM, H323, etc.) does the equipment utilize?

- Will the equipment or software work with outside devices that may be different from your setup?

It’s not a question of “if something should happen...” but rather, “when something happens...” You should find out in advance: What happens when something doesn’t work the way it should?

- Will the company (or companies) provide technical support?

- Are there service contracts?

- What types of service are available?

- What does the service contract cost?

- When is the customer service available?

- Business hours? 

- 24/7 support?

- What is the cost difference on these?

- Will the company repair or replace a defective piece of equipment, or will it wash its hands of the situation, referring you to the manufacturer (who may be in a foreign country)?

- If two pieces of equipment are not compatible, what happens?

- Would you like a single point of contact for technical support?

- Will you have to contact one, two, or maybe three companies for help?

- Who “owns” the technical support process and will ultimately be responsible?

Video and Images:
Most companies offer Web cameras that can be controlled remotely by the physician. Because they can pan, tilt and zoom, they provide a good overall image for communication purposes, but their close- up capabilities are somewhat limited. To get good close-up images of skin, wounds or eyes, however, the remote practitioner will need an examination camera.

Some examination cameras have automatic focus; others are manual focus. Automatic focus cameras may seem to be the easiest to use, but the healthcare provider gives up control of the image to the camera. Occasionally, the camera will have trouble focusing on what the provider wants it to. Getting the camera to focus on the feature you want to see may try your patience and that of your patient and remote assistant. A manual focus camera allows the provider to fine focus quickly on the area of concern and maintain that focus.

Focus becomes important when trying to get a freeze frame of a skin lesion, a mole, an eye or a throat. Can you hold the camera steady enough for a freeze frame, or does the camera’s design require repeated attempts? Where are the camera’s controls? Are they complicated? Are they easily accessible? Do you have to use available light, or does the camera have onboard illumination? Does the camera white balance automatically? Does the camera color balance on skin tones? (This is an important feature to have for patients with darker complexions.)

Questions to consider:

- In order to document the telemedicine visit/consult, what kind of image capture software is available?

- Do you need to store the images in an EMR or a PACS server? 

- Will the solution integrate/work with a minimum of process steps? 

- Can you automate the process and attach DICOM headers to the images?


Customer Service:
Problem A: I’ve called, but nobody there can help me!

Problem B: I’m new here. How does this stuff work?

If you are purchasing from a reseller, what is their relationship with the manufacturer? What type of support do they have from the manufacturer?

After the equipment arrives, you will need to learn how to use it. What type of training is offered? Will the sales representative ever be seen again after the installation? These are good, fair questions that your vendor should be able to answer to your satisfaction. Some options for training should include:

- On site installation

- On site training 

- Remote training (using your new telemedicine system)

- Manufacturer’s training

- On site at the manufacturer’s headquarters

- Regional training class - Is remote support or refresher training offered?

- Is additional, advanced technical training available for BioMed or IT staff?

In business, as in medicine, reputation counts. Ask the company for customer references. Contact these practices to find out about their experiences.

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