Maximizing the benefits of telehealth requires gaining competence in technology, knowledge of laws
Presenter: Neel Naik, MD, Weill Cornell Emergency Medicine, Center for Virtual Care, New York City
Maximizing the benefits of telehealth in practice. Presented April 27, 2023.
Telemedicine is here to stay and is evolving post-COVID, necessitating that practitioners develop competence in the technology to maximize its benefits and stay abreast of the latest laws governing its use.
“Now that telemedicine is out of the bag, patients like it and they want it,” said Neel Naik, MD, citing a 2022 survey from McKinsey & Company in which 60% of patients indicated that they chose telehealth because it was convenient and 55% because they were much more satisfied with the telehealth experience versus in-person care. Further, 63% said that they were interested in broader digital health solutions such as online scheduling and a virtual-first health plan. (In contrast, physicians responded that they were much less enthusiastic about telehealth.)
Attempting to recreate the physician-patient construct over the camera is a source of discomfort to many providers, especially when asked to perform tasks such as the physical examination without the appropriate training, he said. Physician-guided self-examinations, however, are possible through telehealth visits, said Dr. Naik, from Weill Cornell Emergency Medicine, Center for Virtual Care, New York City. “If we ourselves aren’t comfortable on camera taking care of our patients and we ourselves are uncomfortable with the technology, our patients sure aren’t going to feel comfortable and they’re not going to have the faith to listen to us,” he said.
The utility of telemedicine is not as a replacement for in-office visits but to augment in-hospital and in-office care, and can serve to eliminate gaps in care, such as missed in-person appointments due to lack of time or transportation or difficulty ambulating.
He expounded on the essentials of effective telemedicine, from setting up a virtual examination room to developing an opening script. The virtual medical encounter should take place from either a medical office or a home environment conducive to medical care, meaning that the encounter should be free of background noise and disruptions and be performed in a well-lit room. The physician should wear an identification badge and ideally a white coat, as in an in-office setting. “There should be nothing present to detract from the encounter,” he said. Look into the camera when interacting with the patient, he said, so as to simulate eye-to-eye contact.
The opening script should set the stage for the remainder of the encounter and include an introduction and a request for consent to conduct the visit virtually. In this way, the patient is mentally prepared to have a medical encounter. The identity and the location of the patient should be confirmed, as well as the presence of any off-camera individuals in the patient’s space, to ensure that the encounter is private and the patient is free to discuss their medical care. Sometimes, a parent or spouse may be accepted in the room with the patient and can assist in taking a history. Physicians should also be familiar with the televisit set-up prior to the encounter, ensure that they are framed in the center of the screen, be able to do minor troubleshooting in case of glitches, and quickly suggest moving the visit to a later date or to an in-person visit if resolution of technical difficulties would be a lengthy process. Whether the virtual visit is with a new or established patient, “do visits the same way every time so you don’t have to think about it,” he advised.
The legality of the virtual visit must also be considered. Telehealth laws were relaxed during the pandemic but the public health emergency (PHE) declaration that extended telehealth flexibilities is set to expire on May 11, 2023, at which time health care providers and health plans are bound by the Health Insurance Portability and Accountability Act of 1996. The Consolidated Appropriations Act of 2023 extended many, but not all, of the telehealth flexibilities authorized during the COVID-19 PHE through December 31, 2024.
Remember that laws, including prescribing laws, are dictated by the state in which the patient is located, where providers must be licensed to conduct telehealth visits. Also, privacy laws vary by state. Currently, 35 states are single-party recording states and in those states, patients may record the visit without the knowledge of the provider.
Some components of a physical examination can be conducted via a virtual visit through demonstration on camera, said Dr. Naik, who recounted instances of diagnosing appendicitis by having patients perform an abdominal self-examination after a demonstration and then directing them to an emergency room if they report tenderness.
Community tele-paramedicine combines community paramedic visits supervised by emergency physicians via telemedicine with intensive case management, affording high-risk with high-quality emergency care, and is proving particularly useful in managing patients with heart failure to reduce the frequency of hospital admissions, said Dr. Naik.
Reference
Cordina J, Fowkes J, Malani R, Medford-Davis L. Patients love telehealth—physicians are not so sure. McKinsey & Company, 22 Feb. 2022.
Disclosures
Neel Naik, MD, reports no relationships with entities whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.