8- TELEMEDECINE & TELEHEALTH by PHARMAGEEK

Many healthcare providers have been working to define and implement a telehealth strategy over the past several years. In the initiatives I’ve been involved with, this has generally been a slow march through figuring out the legal, reimbursement, compliance, and physician staffing and compensation implications.

With current events, this timeline has obviously accelerated, with IT and clinical staff being tasked with standing up telehealth programs in weeks, if not days, to deal with COVID-19.

Telehealth is a key tool to limit visitors at a time of overcapacity, to reduce the risk of infection spread, and to manage non-Covid-19 care when clinics are closed.

Below I outline some of the key considerations I have seen in my work with telemedicine, and what that might mean in the near term for health systems scrambling to deploy telehealth functionality as soon as possible.

Here focused on synchronous, clinician to home-based patient communication, although launching other forms of telemedicine (clinician to clinician, virtual ICU, etc.) will have similar concerns.

TECHNOLOGY

For both hardware and software, there is limited time to go through assessments and procurement processes.

Given the time-sensitivity, the focus should be on understanding what is available to be deployed immediately. For hardware, that may mean distributing laptops to ensure clinicians have access to camera and microphone-equipped PCs, or even redistributing hardware from training rooms.

For software, this will entail understanding precisely what applications you currently have available, and what the licensing implications would be to scale up to additional users.

If a new application or additional licenses are necessary, it is important to pull in legal and supply chain as soon as possible to ensure an efficient contracting process.

OPERATING MODEL

The technology for telehealth is relatively easy, but getting clinician, compliance, and revenue cycle leadership buy-in is not. I recommend immediately standing up a taskforce with accountability for decision making and defining policies and procedures.

This group should include your IT, EMR, HIM/privacy, compliance, and physician leadership. They will be tasked with determining who is staffing the telehealth service, what the patient consent process is, patient and clinician support, and how documentation will be entered into your EMR.

Since time is of the essence here, pulling this group together for a couple of long work sessions is likely the most expedient route.

TRAINING AND SUPPORT

You will need to be able to quickly and efficiently train your providers, IT help desk, and scheduling and registration staff. Reception and call center staff will need to know the basics to direct patients to online appointments.

Clinicians will need tip sheets on configuring hardware, installing software, and managing appointments and documentation. Help desk staff will need to understand setup and troubleshooting, including working with “non-standard” devices as clinicians work from home.

You will need basic how-tos for your patients, and coordination with your marketing and web teams to publish information and links to your telehealth service.

LONG-TERM PLANNING

The version of telehealth that you roll out overnight is not likely to be the ideal model.

Once your immediate telehealth service is operational at scale, your focus can turn to the longer-term view. This plan should be focused on patient and provider usability, integration with your existing patient portal and digital front door, and seamless interoperability with your EMR.

Scoping out the new interfaces, services, or UI integration will allow you to plan for and allocate your team over the coming weeks. While the immediate need for Covid-19 screening is urgent, telehealth will continue to be very relevant over the coming months to allow non-Covid-19 business as usual for those with chronic conditions or requiring prescription refills.

For medical students with the University of Arizona College of Medicine – Tucson, weeks of suspense will end on March 15. Otherwise known as Match Day, it’s the day the students will learn where they will go for their residency training, in their chosen medical field, after they graduate from medical school in May.

Sarah Joy Ring, who has completed the College of Medicine – Tucson’s Rural Health Professions Program and a 16-week Rural Health Distinction Track, is hoping for a residency focused on both pediatrics and emergency medicine, potentially in a rural location.  Her “capstone” paper, an in-depth research project that all Distinction Track students are expected to complete, carries the impressive title of “A Survey of Rural Emergency Medicine and the Discrepancy of Care for Pediatric Patients that Present to Rural Emergency Departments.”

During her training, she had opportunities to see how important telemedicine can be in rural communities.

“I was at sites that had telemedicine capabilities and spent some time chatting with the physicians about them. "I can specifically remember two experiences, one while on my family medicine rotation in Tuba City (in northern Arizona, where students learn about American Indian healthcare) and one during my RHPP summer in Flagstaff” (also in northern Arizona).

“Tuba City experiences a significant shortage of mental health providers in general, and specifically for children and adolescents," Sarah says.

“As such, they found using telemedicine helpful to connect the children of that region with services that they would otherwise struggle to receive, due to having to travel large distances to receive help, which incurs financial and time burdens for families.

“Moreover, a point that I found particularly enlightening when learning about this service, was with regard to what it means to live in a small population where it is quite likely you know most people living in the region," Sarah says.

“The physicians found that because of this, many adolescents experiencing difficulties often felt uncomfortable sharing with people who lived in the region, out of fear that they may tell someone, or that they were themselves a relative or family friend, which can be a common experience. Having someone to share with who lived out of the region and was not specifically invested in the region and an integral member of the community made many of these adolescents more comfortable with disclosing their experiences.  

“I also worked on writing about how telemedicine can be used to augment pediatric services in rural emergency departments for part of my "capstone" project and found some very positive results from multiple studies. For critically ill patients, one study found that in particular, telemedicine consults improved the access to critical care specialists, resulting in a reduced frequency of physician-related medication errors. Moreover, another study found that parent satisfaction was higher with telemedicine consults than with phone consults, which is a particularly important outcome when caring for pediatric patients and their family. Many of these same findings also translated to the pre-hospital environment, where ambulances that utilized telemedicine resulted in better assessments, more interventions in the pre-hospital environment, and improved outcomes for pediatric patients in pre-hospital care. 

“Overall," Sarah says, I think that we will continue to find that telemedicine is an excellent resource for rural providers that allows patients to have clinically significant access to additional resources and care that would otherwise be difficult or unavailable to the region."

Using telehealth technology still requires good bedside manners - just call it your screen side or website manners. So what do providers need to know that is different between an in-person encounter compared to a telehealth encounter? 

The space involved with making that first impression via telehealth is significantly smaller than meeting in-person in a clinical setting.  Besides being two-dimensional, your space is limited to the size and quality of the monitor projecting your image on the other end of the connection. 

You only get one chance to make a first impression – so make it good.

Important factors to consider to help develop and maintain a positive patient-provider relationship:

Prior to encounter – being prepared is always the best practice.

• Equipment – understand how to use and test; know who to contact to troubleshoot; ensure good placement of the camera, microphone, and speakers
• Physical space – clear of distractions; good lighting; private and secure (HIPAA)
• Provider Appearance – professional; solid, non-distracting (preferably light blue) colors
• Preparation – review patient history chart/file

During the encounter – a little extra explanation can go a long way to foster relationships.

• Confirm connection quality (hear/see) and security of space (HIPAA)
• Introduce self (and others), organization/location
• Have patient introduce self and any others in the room
• Explain the process of taking notes, and only briefly looking away from the camera as necessary, otherwise maintain eye contact
• Periodically ask the patient if he/she has any questions or anything to say
• Reiterate any instructions or follow-up procedures for a patient prior to disconnecting

Developing your screen-side manners in today’s telehealth world is just as essential as developing good bedside manners. 

Patients still need to feel they are being heard and understood by their provider whether in-person or via video connection. The tasks that happen during an in-person visit, (e.g., jotting down notes, or looking at an image), are seen directly by the patient.

These same actions may not be as visible via video, and require some explanation to keep the patient engaged. The patient still needs your full attention.

Empathy is no less important in telemedicine. Being prepared, clearly communicating, and focusing on your patient will help foster a positive patient-provider relationship.

 You can still make meaningful eye contact via telehealth, but the trick is looking directly at the actual camera, and not the projected image of the patient on your screen.

Body language can speak louder than words, but telehealth creates a situation where not all body language is actually visible. 

While a thoughtful hand to the chin while thinking maybe commonplace, on video the same action might communicate disinterest. 

Controlling reactionary movements is vital for telehealth. While standing bedside, a simple action like shifting weight from one leg to another has minimal visual impact compared to being on video and then seeming to shift out of the view of the camera.

Similar to developing a good bedside manner, a good screen-side manner takes practice.  Telehealth is unique in that you can record yourself and review the video before ever connecting with a patient.

By examining your recording, you can get a better understanding of the patient’s perspective of the telehealth connection. This process allows you to make adjustments that might not happen otherwise, creating the best patient encounter possible.