Telehealth

Introduction

Telehealth is the distribution of health-related services via electronic information and telecommunication technologies. In the light of the COVID-19 pandemic and recommendations for physical distancing, live video telehealth allows for continued, albeit virtual, patient and clinician contact in a variety of settings including home health, outpatient appointments, the emergency department, and remote ICU monitoring (Hollander and Carr, NEJM 2020). Acknowledging the value of virtual visits in the COVID-19 era, Medicare and other insurers have committed to providing reimbursement to providers for telehealth video visits.

Although the advantages of live video telehealth are numerous, there are several challenges for ensuring equity and privacy for its users. Clinicians must be sensitive to the barriers that may prevent some patients from owning basic technology such as digital mobile technology that is required for participation in virtual visits. Furthermore, certain individuals' home lives or inpatient shared rooms may not allow patients enough privacy to feel comfortable speaking about their health concerns.

Despite these limitations, telehealth holds great promise for increasing our health care system’s capacity for providing care to patients while reducing the risk of viral exposure for both patients and healthcare workers and reducing the use of limited personal protective equipment. Although telehealth has been increasingly used in the past several years, its use has been largely limited to rural and other access-poor settings. Experience with telehealth in these settings suggests high patient and provider satisfaction, owing largely to the flexibility and convenience offered by this modality.

However, despite recent increases in telehealth, many clinicians and students will have never used this mode of care delivery before and even fewer will have received telehealth-specific training. It is important to consider best practices for telehealth visits, including how to translate in-person clinical skills to the virtual settings. Telehealth promises to become increasingly integrated into our routine care delivery system, and it is thus important for clinicians and students to gain familiarity with this model of care delivery.

Components of Telehealth Visits

In this section, we will focus on live video telehealth as part of outpatient visits, though the best practices highlighted here may be applicable to other clinical settings as well. Similar to in-person clinical visits, telehealth visits include distinct components.

Before the visit

Much like in-person visits, telehealth visits rely on appropriate preparation and rapport building to help set the stage for a successful encounter. The American Medical Association’s Telehealth Visit Etiquette Checklist summarizes some of the key considerations in setting up a telehealth video visit.

Preparation includes gathering the necessary personnel, technology, and materials. All relevant members of the interprofessional care team, including trainees and an interpreter if needed, should be present either physically or virtually before the visit begins. A caregiver may also need to be with the patient for the visit. Many of the interpersonal skills that clinicians rely on in the in-person setting to communicate warmth and attention can still be used over video visit. To communicate eye contact specifically, clinicians should make sure that they are looking directly at the camera rather than at the screen or their notes.

In terms of technology, both audio and visual elements should be optimized. Visually, the lights must be bright enough for the patient to see well, and a neutral, professional dress and background are preferred. Clinicians and students should check for internet and microphone quality, and be prepared to adjust the brightness or volume for patients with visual or hearing impairment. It is also important to have a backup plan if problems with connectivity arise during the visit. Lastly, because the screen provides a limited view of the clinician, the team should ensure that all equipment and materials are within reach to avoid the need to move off screen during the visit.

During the visit

The visit begins by obtaining informed consent to conduct a virtual visit, orienting the patient to the video environment, and establishing a patient’s location and contact information in case of an emergency. If the telehealth encounter occurs in the inpatient setting, where the team may be large and may change from day to day, introductions and clarification of the clinician’s role is critical as well. Involving caregivers may be helpful, especially if a patient is unable to provide a history themselves.

Next, the same skills for taking a history in an in-person visit should be used during a virtual visit, using clinical judgment for which questions to ask and prioritize. In geriatrics, for example, specialty-specific best practices used in in-person settings can be applied to telehealth. In addition to the usual information gathered during an in-person visit, outpatient telehealth visits can allow clinicians to observe patients in their home, which can help them better understand the physical and social environment in which patients manage their medical conditions. Other novel strategies can be used during this part of the encounter to gather information from patients. For example, when reconciling medications, clinicians can ask patients to show their medications on camera and double check their supply. Additionally, some aspects such as advance care planning may be even more important during the current pandemic. Clinicians should take extra care to speak loudly and slowly and to make time for questions.

The physical examination remains an important component of virtual visits. Observation is a critical part of the virtual exam, as clinicians can gain valuable information by, for example, observing a patient’s environment, general appearance, and effort of breathing. More detailed elements of the exam, such as a focused joint exam or neurologic exam, may require participation of the patient and can also be conducted. Vital sign measurement can be accomplished if the patient has the proper tools at home or if monitors are attached in the inpatient setting. A caregiver or nurse can also be involved to help conduct certain maneuvers, such as measurement of orthostatic vital signs. Creative approaches like these allow for the physical exam to be translated to the virtual setting. However, it is important to recognize that some maneuvers--such as auscultation of the heart or lungs--may be more difficult to adopt and may require in-person evaluation. As such, one important function of the televisit is to assess if a patient requires a higher level of care.

Ending the visit

Much like in-person visits, telehealth encounters conclude with a discussion of the assessment and plan. During this part of the visit, clinicians can provide education to patients, answer any remaining questions, and set expectations for follow up. For example, a patient may need labs, imaging, or consultation with a specialist. In the outpatient setting, a patient can make a follow up appointment as well. Written materials can be shared with patients through secure electronic message, mail, or fax. Finally, it is important to allow the patient to conclude the visit.

Like for in-person visits, the team should then determine any remaining “to-do” items associated with the encounter. In the inpatient setting, this could include virtual consultations or updating family members. If necessary, the team can review their telehealth process and make changes for continuous improvement of this rapidly evolving modality.

This module was written based on work originally created by Dr. Andrea Schwartz. For more information about telehealth in the geriatrics setting, please see her recorded presentation here.

Thought questions:

• Imagine you are working in clinic and see both Brian and Diane on your schedule as televisits.

  • Brian has developed a cough and scheduled an urgent televisit. How will you orient Brian to this new format? How might you decide whether he needs to be seen in person?

  • Diane has scheduled a routine telemedicine appointment with you for follow-up of her COPD, heart failure, depression, and anxiety. What would you look for during a virtual visit physical exam?