We all know that telemedicine has taken off like a rocket ship in the past year, largely expedited by the Covid pandemic. Many patients don’t want to sit in the potential petri-dish of infection commonly known as the waiting room. This article will not delve into all the other reasons that telemedicine will do well. This is a given and there is a lot of literature to back it up. Rather, I will attempt to provide a basic list of things that a doctor should consider before starting a telemedicine company from the ground up. If you want to add a “telemedicine wing” to your current bricks ‘n mortar practice, this is article is not for you. I am focusing here on starting a full-time telemedicine practice.
Who am I? I started the “construction” of a niche telemedicine practice that has just begun to take on patients, and it has been a full-time learning experience as well as a full-time experiment. I chose to take on this challenge myself, with a “boot-strap” budget, that is, I funded the initial seed round of funding out of my pocket to the tune of about $70K. I have been asked by some physicians who want to get into telemedicine on their own as I did, (versus being a “hired gun” for a pre-established telemedicine company such as DoctorOnDemand) how to go about it. First off, you should realize two things: (1) unless you have a few million dollars to initiate your second-tier funding (known as the Series-A round), you should realize it can cost a lot to fully “launch” a stand-alone telemedicine practice (more on this later), and (2) you should devote, or find someone else to devote, full-time hours to the endeavor, such as a Practice Manager or Operating Officer with telemedicine experience. It is challenging enough to practice full-time “bricks ‘n mortar” medicine and start a telemedicine practice at the same time without assistance. Lawyers, accountants, and consultants are important to help you navigate the waters. Friends and family should help you beta-test what you are creating.
What follows are 15-steps that you might want to consider and that I learned through the school of hard knocks & on-the-job training. I did read a lot of reading (business, marketing, insurance, billing, stages of funding, and of course, telemedicine.) I even worked for a month for a telemedicine company before starting my own company, to get the feel of it. Alternatively, instead of starting your company “from scratch”, you can find experts who will guide you. How much you decide to do alone and how much by other people will determine your startup cost. I currently am looking for my first institutional funding round, known as the Series-A round.
Here are the steps, not in chronological order or even by order of priority. This is because many of these things will occur concurrently.
- Incorporate an MSO (Medical Sources Organization), separate from the licensed Professional Medical Provider. The lawyers recommend this so as not to have legal cross-liability between the two companies. Have Articles of Incorporation and Articles of Organization for each company (ask your lawyer or engage him/her to do this). Cha-ching! The MSO will funnel patients into the EMR used by your Providers. Try to recruit a Board of Advisors from the telemedicine world (not a Board of Directors just yet). Pick their brains for free if you can. You can Google “telemedicine advisors” to get started. Remember that corporate and medical compliance is important. If any questions, check with your state’s Board of Medicine and Secretary of State, and of course, make sure you have established a separate medical malpractice clause or policy for telemedicine that covers all your Providers.
- Create/build a slick and professional website for your MSO and establish emails that look professional and customized. DrSoAndSo@ gmail.com is not professional – DrGuha@GuhaMD.com is. Use a hosting service to create your emails. Google “creating a website” or “hiring a web designer” and “establishing a custom email” and delve into the choices. The MSO website should seamlessly feed into your HIPAA-compliant EMR, and make sure that all communication to/from the patient goes through this website. Regular emails and texts should never contain identifying information or PMI (Private Medical Information). Your MSO site will feed into your Professional Medical Provider site/EMR, which should be linked up to a good telemedicine billing company. You can also establish a contract with a laboratory company and have them build an interface to your EMR so labs can be checked effortlessly in just one place, your EMR!
- Pick solid legal representation. An attorney that is proficient and has experience in both telemedicine and startup companies is best, but this is rare. The attorney should be able to guide you through the legal and financial aspects of doing telemedicine in your state. If you have Providers licensed in more than one state, you can practice in each state in which you have a Provider, provided the calls are routed to the correct Provider.
- Engage a good accounting company that has done startups, preferably telemedicine startups. Most “standard” CPAs do not have experience with startups. Don’t choose your neighbor down the street - the CPA that you golf with every Saturday. Create a 3-year financial projection spreadsheet and realize it is nearly meaningless if you picked a telemedicine niche that is relatively new like I did. I recommend paying the Providers a percentage of the revenue from each encounter they complete rather than paying a “base salary”. Build this into your spreadsheet. This motivates the Provider to stay busy because they only make money by actively doing encounters.
- As one expert telemedicine consultant has told me realize that you are now in the marketing business, just as much as a medical business. And as a marketing company, you need to start thinking along the following lines...
- Make sure your MSO has a continual presence on Social Media, such as Facebook, Instagram, Twitter, LinkedIn, and eventually YouTube. Create (or pay someone to create) your own corporate pages under the company’s name. Personal pages are not optimal. You can do more than one page on most of these platforms, so having a personal page will not prevent you from creating a company page. The LI page is NOT for patients, but for networking with other professionals/consultants on your business and is a good source of finding members to serve on your Board of Advisors, whereas the Social Media pages are to attract patients. Write articles and post videos of yourself on a regular basis on your Social Media company’s pages continually. This will improve your overall online presence. Social Media is dynamic and requires attention on a regular basis. Most Physician’s hire someone to do this, but a lot of the content should initially come from you.
- A HIPAA-compliant EMR (e.g., PrognoCIS.com) that is patient-centric, user-friendly, customizable, well-tested, and with good support is mandatory. The EMR should be easy for the physician to navigate as well, and the company should provide plenty of support and training. I don't recommend trying to create a ”free page” using a Godaddy-type company since this probably won’t be HIPAA-compliant and just won’t look as good, unless you are a web-whiz. Have family and friends test the professionally-designed site(s) as they evolve to fruition. Remember that a website is like a garden – it constantly needs “planting, weeding and pruning”. It is dynamic and not static. Make sure that your web-designer knows Search Engine Optimization, SEO. This is basically regarding the search terms that people may type into a Google/Bing search to find you. These terms should be in/on your sites. SEO is a science unto itself.
- Realize that growth of the practice requires patience and that “organic” (non-marketed) growth will take time, usually months to a year if all is done right, before you get the traction you need for the next round (Series-A) of testing. You probably will not have patients breaking down the virtual doors to sign up right away, no matter how attractive and slick your site is. They must find you first (see SEO above) and be willing to trust you with their medical histories. This is why marketing is so important. Telemedicine is not a “build it and they will come” endeavor.
- Try to focus on a “niche” in telemedicine rather than a one-size fits all site. For example, the company that used to be called Roman, started out to treat erectile dysfunction. Since it was successful with ED treatment, it has recently evolved into “Ro”, with multiple other medical services - now with its own pharmacy, and treating smoking cessation, premature ejaculation, cold sores, and genital herpes. It’s marketing budget is huge, in the millions. My niche is serving the specific needs of the underserved LGBTQ community – www.LGBTQ.clinic .
- Establish relationships with a laboratory company (e.g., LabCorp and/or Quest) to be able to order labs remotely and better still, also partner with an in-home lab testing company (e.g., MyLabBox.com) so patients don’t have to leave the house for certain “sensitive” labs, such as for STDs.
- e-Prescribing is crucial as well, through companies such as Identrust. You should be able to send an electronic prescription to any US pharmacy directly from your EMR.
- Have an outreach and referral program for the nodes of influence in your niche. For example a company that focuses on treating Peyronie’s disease might have outreach and referrals to Urologists and Urological specialty associations.
- Get your Professional Medical Provider company credentialed to take insurance payments through the major payors in you state(s) (such as BCBS, etc.). This is generally done by a medical billing company. Accepting Medicare is also a consideration if you are targeting an illness that occurs in the geriatric population. Some insurers require a physical site at which you can examine patients, and some do not. You can avoid this by taking “cash only” customers. Subscription models also are a good thing and don’t have to involve insurance.
- This recommendation is multi-factorial and basically involves the marriage of all the components above into one smoothly functioning, seamless whole. That is, the MSO, Medical Provider, Laboratory companies, the billing company, a HIPAA-compliant EMR, and the marketing campaign – all have to work together to make the patient-experience attractive.
- OPTIONAL: If you want to grow LARGE, explore funding opportunities if you want to grow after your seed round and have completed your MVP (Minimum Viable Product – all of the things in #14) is up and running, and you can show some traction, i.e., taking real live patients and earning real revenues.
There are more things to consider than what can be presented in this short article, but these 15 steps will hopefully give you a starting point should you want to start a proprietary telemedicine practice. 😊
Dr. S. John Guha