Many practices are investigating the use of telemedicine to offer services while minimizing risks to their patients and staff. For those practices that have not established telemedicine, there are several key elements that should be considered. Telehealth and telemedicine may be defined by state laws and regulations, but the specificity may vary widely. In addition, compensation for providing telemedicine services will also depend upon the patient’s insurance provider, therefore impacting reimbursement. In addition, the use of technology to communicate with and evaluate patients requires attention to privacy and security practices as well as assuring the standard of care is met.
Risk Management Recommendations
As more and more healthcare providers begin to use telehealth to care for their patients, it is important to always remain mindful of general patient safety, the individuals’ clinical care needs, and what would always be your fundamental guiding light--the standard of care for your clinical decisions. Utilize all the risk mitigating and patient safety tools you would normally use—that of thorough communication, coordination of care, and documentation of both, as well as your clinical thinking and decision-making process.
- Ensure the patient’s condition can be appropriately examined via available telehealth equipment. Determination of telehealth appropriateness will need to be made, e.g., can the patient be adequately assessed without information normally obtained during an office visit.
- Ensure the patient has the technology and connectivity necessary to be adequately examined and the capability to utilize the technology needed. Have a back-up plan in case something goes wrong, i.e., have a telephone number for the patient in case the video visit does not work.
- Recognize that some patients might not be comfortable with a video visit and might require a phone visit or in-person if available.
- Ensure that you are examining and prescribing for the correct patient. Some ways to authenticate the patient include:
- Asking the patient to hold up a driver’s license to the camera and comparing the information on the identification card to the information provided by the patient.
- Running an insurance eligibility check, confirming the patient’s name, address, date of birth and Social Security number.
- If the patient has been seen before, asking a series of questions on prior medical history to determine if the patient responses match what is in the medical records.
- Thoroughly document the encounter as you would any face-to-face encounter, including all communications with or about the patient, review or ordering of tests / results and follow-up recommendations, coordination of care, etc.
- Document the informed consent process and confirmation, including that the patient agrees to and understands the limits of confidentiality when communicating via an electronic medium and that it may be determined that telemedicine is not appropriate for the diagnosis and treatment of his or her condition.
- Document any technical issues that interfered with, delayed or complicated the telemedicine encounter. For example, poor internet connectivity or signal quality, camera or device malfunction, tele-presenter unavailability, patient inability to manage technical aspects of the exam, or peripheral device unavailability.
Telehealth and the Patient Experience
In addition to ensuring that the process aspects of telehealth are adequately addressed, physicians can take additional steps to improve the patient experience.
- Clearly communicate with patients that telehealth is available, how to schedule a visit, and what the visit will look like.
- Set expectations with patients regarding telehealth visits. Acknowledge with patients that a telehealth visit is not as personal and will feel different than an in-person visit. Emphasize that although the visits look different, the patients are still receiving quality healthcare.
- Be especially conscious of your tone and convey warmth and empathy when appropriate.
- Address the emotional needs of patients by acknowledging the impact of the COVID-19 pandemic and the uncertainty of the times.
- Bring structure to the telehealth visit by setting an agenda. Ask for and identify the patient’s primary concerns and priorities for the visit. At the end of the visit, summarize the plan of care and emphasize any follow-up concerns.
- Ask the patient open-ended questions to encourage communication and allow time to address questions from the patient.
- American Medical Association (AMA). “AMA Quick Guide to Telemedicine in Practice”
- The Center for Connected Health Policy’s (CCHP) National Telehealth Policy and Resource Center (NTRC-P) is a nonprofit, nonpartisan organization working to maximize telehealth's ability to improve health outcomes, care delivery and cost effectiveness. One of the most exhaustive resources; it is a very robust and easy to use website. Lists 50-state laws, reimbursement regulations, policies, resources and multiple links (as well as telephone contacts) for detailed resources and information. (Membership is required to access the content, but membership is free).
- In response to the COVID-19 virus, the Office for Civil Rights, U.S. Department of Health and Human Services has issued BULLETIN: Civil Rights, HIPAA, and the Coronavirus Disease 2019, in March 2020, to address how patient information may be shared under the HIPAA Privacy Rule in an outbreak of infectious disease and to remind covered entities and their business associates that the protections of the Privacy Rule are still in force during an emergency. Additional enforcement discretion has been provided by the OCR during this “nationwide public health emergency,” specifically addressing use of remote communication technologies that may not fully comply with HIPAA requirements.
- The National Consortium of Telehealth Resource Centers (NCTRC) is funded by the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA). Telehealth Resource Centers (TRCs) located throughout the United States work collaboratively to provide information and assistance to telehealth providers.
- The Center for Medicare and Medicaid Services (CMS) has issued information and guidance on telehealth related to the President’s Emergency Declaration.
Specialty Specific Resources
- American College of Obstetrics and Gynecology. "Implementing Telehealth in Practice"
- American Academy of Dermatology guidelines and directives. (Must be a member.)
- American Psychiatric Association. "Telepsychiatry". (Membership is required to access the toolkits and resources)
- American Academy of Allergy, Asthma, and Immunology. "State Specific Requirements for Telemedicine Use"
- Society for Maternal Fetal Medicine (SMFM). “SMFM Coding White Paper: Interim Coding Guidance: Coding for Telemedicine and Remote Patient Monitoring Services during the COVID-19 Pandemic”
- American College of Rheumatology. “Telehealth Provider Fact Sheet”
- American Academy of Family Physicians. “Using Telehealth to Care for Patients During the COVID-19 Pandemic”
- American College of Cardiology. “Feature | Telehealth: Rapid Implementation For Your Cardiology Clinic (Updated March 24, 2020)”