Best Practices For Providing Telehealth Services
This is the second installment of a two-part series about telehealth.
Part one addressed fundamentals; in part two, we discuss best practices.
Practicing telehealth, in particular synchronous video visits, requires a distinct set of skills. The same etiquette used during in-person visits still applies, but must be augmented to fit the technology and optimized for user experience.
For fellows interested in providing telehealth services, below are a few suggestions based on my own experiences and inspired by published guidelines.
- Ensure your workspace is ready. Reliable internet connectivity is crucial.
- Proper attire – easy to forget when you are in your living room – could include a white coat.
- Good lighting and privacy is mandatory. Appropriate backdrop is necessary, such as your office or room with a white wall. Remember that patients will see your dog sitting on the couch or your child running in the background.
If providing team-based inpatient care,
- Discuss with your advanced practice provider (APP) or nurse prior to entering the room, ideally in a workroom.
- Understand both clinical and psychosocial concerns (i.e. if a patient wants to see a doctor in person and requests hospital transfer). Presenting a competent, evidence-based and patient-centric plan when in the room can many times can lead to better patient outcomes and a patient decision to stay, rather than travel several hours to the next hospital.
Be "Physically" Present in the Room
- Introduce yourself as the telehealth/telemedicine physician. Remember this may be the first time a patient or family have interacted with telehealth. Make eye contact with everyone.
- Ensure that the cart position allows you to see and hear the patient clearly. Usually this is at the foot of the bed. For those hard of hearing, the side of the bed may be better.
- Not everyone in the room may be visible on your screen. Clearly ask who is in the room, and introduce yourself to everyone. Create an environment of trust, where anyone can voice questions, concerns or provide helpful background information.
Describe What to Expect
Clearly state your role as the physician who leads a team of APPs and nurses trained to evaluate, diagnose and treat patients remotely. This step usually involves first gathering information from a patient interview and then a physician-directed physical exam using peripheral devices, such as a digital stethoscope.
Perform a Thorough Physical Exam
- Communication and teamwork is key.
- Clearly state that your APP or nurse will perform the exam following your specific directions.
- Similar to an in-person exam, perform your exam in a structured and complete manner.
- If you cannot see or hear, ask for the cart to be moved or the part of the exam to be repeated. Your APP or nurse should describe where the stethoscope is placed (i.e. right lower lobe, left upper sternal border, etc.), but also confirm placement through visualization. All of this requires education, training and commitment for all those involved.
The goal of telehealth is to provide patients with trusted, knowledgeable clinicians that can provide superb care and care experience. Achieving proficiency in telehealth delivery allows us to focus on what Francis W. Peabody, MD, reminds us in his 1925 essay, The Care of the Patient:
"The treatment of the disease may be entirely impersonal. The significance of the intimate personal relationship between the physician and patient cannot be too strongly emphasized."
When used properly, telehealth can complement the relationship with our patient – and we need to be ready to deliver this care now and in the future.
This article was authored by Jedrek Wosik, MD (@jedrekwosik), cardiology and clinical informatics Fellow in Training (FIT) at Duke University and the Duke Clinical Research Institute in Durham, NC.