Once the decision to integrate telemedicine into routine care delivery is made, frontline care teams must begin to deliver telemedicine efficiently, safely, and equitably.

The key considerations for frontline teams include:

  1. Provider and team devices,
  2. Developing telemedicine visit workflows,
  3. Ensuring care visit quality and safety, and
  4. Supporting staff and team well-being.

Provider and Team Devices

Telemedicine requires internet-connected devices with a camera, microphone, and speakers. These range from smartphones to tablets to computers. There are several key challenges with provider devices. The privacy and security considerations for health care settings are discussed in the chapter of this toolkit devoted to privacy and security. For offsite clinicians, there are specific considerations for telemedicine delivery. Many health care teams use personally-owned devices to deliver or participate in telemedicine workflows. The resources below address common general provider- and system-facing challenges, as well as ones that have emerged as a result of the enforcement discretion during the pandemic. Main recommendations for improving cybersecurity for provider and team devices include using encrypted technology, utilizing a virtual private network (VPN), and employing strong authentication parameters.

Health Care Team Workflows

Staff Roles. Telemedicine necessitates multiple new staff roles and workflows, including program management, site coordination, clinical oversight, technical support, and more. It is critically important to build in staff expertise and adequate time for patients with varying levels of digital literacy to successfully join and participate in telemedicine visits. Many clinics are experiencing a higher visit volume with telemedicine and scheduling should account for this higher show rate. During a visit, it is critical that each team member know their role and the needed electronic medical record documentation practices.

Scheduling and Triage. Determining whether telemedicine vs. in-person care is more appropriate, is the first step in carrying out new telemedicine workflows. The resources below offer guidance on how to approach scheduling and triage with a telemedicine system in place.

Schmidt. NEJM Catalyst. 2020

Workflows. Delivering high-quality, equitable telemedicine care requires new workflows and protocols. Transitioning team-based workflows from in-person care to telemedicine is an ongoing challenge, and many health care settings are currently experimenting and innovating on how to do this well. The resources below offer real-world examples of how various health systems have approached these aspects of telemedicine implementation, including several examples from public and FQHC sites specifically.

Velázquez et al. NEJM Catalyst. 2020

Conducting Safe and Appropriate Telemedicine Visits

Diagnostic Safety Considerations. Many clinicians may have concerns that with telemedicine, they may make an incorrect diagnosis or miss a clinically important finding leading to an adverse event. Patient follow-up during the COVID-19 pandemic is also variable, and it may be more challenging to obtain recommended labs or other testing needed for a correct diagnosis. Evidence has shown that telemedicine has similar diagnostic accuracy as in-person visits for common conditions, though if uncertainties or red flags arise, appropriate triage and referral to in-person care is important.

Clinical Assessment. The following are some suggestions and strategies for providers to ensure you are assessing and diagnosing conditions as safely as possible via telemedicine services and continuing to provide patient-centered care. Reviewing best practices prior to your first telemedicine visit is an important starting place.

A telephone or video encounter enables clinicians to gather the same SUBJECTIVE information as an in-person encounter (history of present illness, past medical history, etc). In fact, the medication reconciliation may be more accurate as the patient can review their pill bottles at home. For OBJECTIVE information, a patient may be able to check their own temperature, blood pressure, and pulse if they have home equipment, and can often palpate areas of the body or test range of motion with your instruction. With this information, be systematic in formulating a differential diagnosis and recognize that a remote context means your differential may be broader — avoid “premature closure,” meaning narrowing or finalizing a diagnosis too early. National Telehealth Technology Assessment Resource Center: Video Platforms: Clinical Considerations — This webpage has information and a video outlining clinical considerations to keep in mind when using video platforms. They advise, “When a clinical provider is presented a patient.., we inherently consider the information that we have been able to collect and the differential diagnosis of possible conditions….In the setting where the interaction is limited by video, audio, or a textual presentation, it simply means that we are unable to remove some items off the differential when compared to those we may have comfortably removed when seeing the patient in person, or a different setting.”

Mid-Atlantic Telehealth Resource Center: Telehealth Resources for COVID-19 — Within the “Best Practices for Conducting a Telehealth Visit” section of this webpage, there are resources on “Clinical Assessment and the Physical Exam,” including a series of videos on conducting physical exams via telemedicine. In addition, the “Other Useful Implementation Resources for Clinicians and Practices” (also within “Best Practices for Conducting a Telehealth Visit”) has links to specialty-specific resources on clinical considerations for providing care via telemedicine.

 

Promoting Telemedicine Provider Well-Being

In times of crisis such as the COVID-19 pandemic, burnout among those providing telemedicine is a serious concern. Telemedicine providers working remotely may lack the opportunity to check-in with colleagues, team members, or supervisors, resulting in feelings of isolation. In settings where a high proportion of patients have digital and health literacy challenges, the high prevalence of technical problems during telemedicine visits can exacerbate feelings of burnout. The loss of in-person care and dramatic increase in screen time has been called “Zoom fatigue” or “telemedicine fatigue,” and is uniquely physically and cognitively taxing. If you’re feeling this, you’re not alone.

Telebehavioral Health Institute

                          

                           

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