99448 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe

Name of the Procedure:

Interprofessional Telephone/Internet/Electronic Health Record Assessment and Management Service

Summary

This is a service where a consultative physician or healthcare professional assesses and manages a patient's medical condition using telephone, internet, or electronic health record (EHR) platforms. A thorough verbal and written report is provided to the patient's primary or requesting physician.

Purpose

This procedure addresses various medical conditions requiring expert consultation and second opinions. The goal is to offer comprehensive assessments and enhance patient care by leveraging interprofessional collaboration and technology.

Indications

• Complex or unresolved medical cases needing specialist input
• Chronic disease management and treatment adjustments
• Diagnostic clarification
• Advice on therapeutic interventions and care plans

Preparation

• Ensure all relevant medical records and diagnostic tests are accessible in the EHR.
• No specific patient preparation is required.

Procedure Description

1. Initiation: The treating/requesting physician identifies the need for a consultative service and requests it via phone, internet, or EHR.
2. Assessment: The consultative physician reviews the patient’s medical history, current condition, and all relevant records.
3. Communication: Conducts a detailed discussion with the treating/requesting physician and, if needed, the patient.

4. Reporting: A comprehensive verbal and written report is created and sent to the requesting physician, covering assessment, management recommendations, and any follow-up actions.

   Tools:

   • Telephone
   • Internet-based communication platforms (e.g., video conferencing)
   • Electronic Health Record (EHR) systems

Duration

Typically takes 30 minutes to 1 hour, depending on case complexity.

Setting

Performed remotely – from the physician's office, telehealth facilities, or even home offices.

Personnel

• Consultative physician (specialist)
• Treating/requesting physician
• Supporting healthcare staff (if needed for technology setup)

Risks and Complications

• Minimal risks associated as it is a non-invasive procedure.
• Rare risks include miscommunication or technical issues affecting the quality of information exchange.

Benefits

• Access to specialized medical expertise without the need for physical travel.
• Enhanced patient care through timely and expert recommendations.
• Improved coordination and continuity of care.

Recovery

• No recovery needed.
• Follow-up as per the consulted recommendations and primary physician's guidance.

Alternatives

• In-person specialist consultations
  • Pros: Direct physical examination possible.
  • Cons: Requires travel, longer wait times.
• Email consultations
  • Pros: Convenient for non-urgent issues.
  • Cons: May lack immediate interaction for problem-solving.

Patient Experience

• The patient may not directly interact with the consultative physician.
• Minimal discomfort, as no physical examination is involved.
• Potential feeling of reassurance due to the specialist's involvement.
• Clarity in treatment plans and better informed healthcare decisions.