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.
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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.

  • West County Health Centers: Virtual Clinic Workflow Using Zoom Breakout Rooms — This workflow provides a “virtual clinic layout” for care teams using Zoom breakout rooms for telemedicine. It includes descriptions of different administrative and clinical team members’ roles in managing a Zoom clinic, from patients’ first check-in through the telemedicine visit itself and discharge. This tool was created by West County Health Centers — a Federally Qualified Health Center offering comprehensive medical, dental, behavioral health, and other specialty services to the communities of western Sonoma County, California — as part of their work through CCI’s Connected Care Accelerator.

West County Health Centers

  • Petaluma Health Center: Tech Volunteer Workflow — This is a workflow for volunteers providing tech assistance to patients prior to their telemedicine appointments. It includes steps such as checking whether patients have email addresses, eClinicalWorks patient portal access, and the Healow and Webex apps, and completing appropriate consent documentation. This tool was created by Petaluma Health Center — a Federally Qualified Health Center offering comprehensive medical, dental, mental health, and specialty care services for communities in Petaluma, California — as part of their work through CCI’s Connected Care Accelerator.

Petaluma Health Center

  • White Memorial Community Health Center: Video Visit Workflow — This is a workflow for scheduling and completing a video visit using Healow, an application from eClinicalWorks. It includes steps such as ensuring patients’ web accessibility, conducting pre-visit planning, sending text message reminders, and following up with patients after the visit. This tool was created by White Memorial Community Health Center — a non-profit health center in Los Angeles, California that provides primary healthcare services to children, adults, and seniors regardless of patients’ ability to pay — as part of their work through CCI’s Connected Care Accelerator. To learn more about how White Memorial improved video visit infrastructure and assessed patient satisfaction with telemedicine, check out this case study.

White Memorial Community Health Center

  • UMMA Community Clinic: Hybrid Visit Workflows — This collection of three workflows provides guidance for scheduling, confirming, and completing hybrid visits using Doxy.me and eClinicalWorks. Some sites have found hybrid visits useful if patients need to come on-site in order to access the internet, devices, or private space needed to complete a video visit as well as to access specialty care that may not be accessible locally. This tool was created by University Muslim Medical Association (UMMA) Community Clinic — a Federally Qualified Health Center and Patient Centered Medical Home in Los Angeles, California providing medical, behavioral health, educational, and other services to promote the wellbeing of the underserved, regardless of ability to pay — as part of their work through CCI’s Connected Care Accelerator

UMMA Community Clinic

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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