TELEMEDICINE Background and benchmarks for planning
FORWARD
Telehealth and telemedicine are well-studied approaches to care delivery, but there is almost no research regarding design of these spaces. 1. Almost no formal research looks at design features that support telemedicine or telehealth 2. Several national guidelines from the US and Canada suggest best practices, but they date from the pre-Covid-19 era of telemedicine and telehealth 3. No one yet knows if recent easing of regulations on telehealth will stick after the Covid-19 national emergency ends. This will impact what kind of information is needed for effective and supportive designs. This review gives an overview of these issues. Due to lack of research, this review, more than most, depends on white papers, industry sources, and media reports. It is divided into the following sections.
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I.
BACKGROUND A. Definitions B. Outcomes C. Traditional patients served D. Covid-19-related changes to telemedicine delivery
II.
EXISTING DESIGN STANDARDS A. Best practices (FGI, 2018) B. Some detailed design considerations
III.
FUTURES A. Programming and planning (delivery) B. Longstanding and emerging patient populations served C. Potential metrics and methods of study D. Real estate downsizing E. National corporate leadership in telemedicine F. Some warnings
I. BACKGROUND A. Definitions - Different meanings of telemedicine & telehealth There are multiple definitions that distinguish telemedicine and telehealth. Examples appear below. Given the variety of possible definitions, it is a good idea to carefully review all remote, telecom-enabled care options and agree on terminologies on a client-by-client basis as part of visioning and programming definition. This review will use “telemedicine” throughout.
4. WHO a.
Telehealth delivers care outside of traditional facilities.
b.
Telehealth uses technology to overcome distance and increase healthcare access.
5. American Association of Family Physicians a.
Telemedicine is medicine using technology to deliver care at a distance. It is a physicianpatient interaction.
b.
Telehealth is the broad description of using technologies to provide services and care from afar.
1. The HIMMS 2017 Review: a.
Telemedicine is provider-provider interaction
b.
Telehealth is provider-patient interactions
2. The American Telemedicine Association a.
Telemedicine is telecommunications to support patient status
b.
No definition of telehealth
3. HRSA/CMS a.
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Telemedicine and telehealth are interchangeable: supporting distance care, education, and health promotion
6. FGI Guidelines a.
Defines telemedicine as including both patientprovider and provider-provider interactions related to healthcare when there is distance between the involved parties
b.
No definition of telehealth
7. CMS CMS does not define “telehealth” and “telemedicine” per se. CMS terminology can be adduced from telemedicine engagements for which Medicare
Figure 1 From CMS; note the three types and definition of services under the emergency declaration
currently reimburses. The current CMS guidelines under Covid-19 conditions categorize all of the following telemedicine activities as billable. (Fig. 1) a.
b.
c.
Medicare telehealth visit: a provider-patient visit that uses telecommunication (which can be outpatient, emergency, follow-up to inpatient and other visit types). This visit type can be used for established patients, or, with some paperwork, for new patients. Virtual check-in: check in between patient and provider ascertaining if an office visit is needed. This involves remote evaluation and exchange of images/video. This visit type is for established patients. E-visits: an exchange between a patient and provider through an online portal. This visit type is also for established patients.
One more useful piece of vocabulary is the “presenter”. A presenter assists in positioning the camera or patient for the provider at the other end of the conversation to get the relevant information.
B. Outcomes - Telehealth improves healthcare quality and access and reduces costs Telehealth has, prior to Covid-19, been especially useful for extending the reach of specialized care expertise beyond the geographic range of the specialist and in enabling health care access for rural and home-bound patients. In a review of 233 studies Tottem and colleagues (2019) found consistent positive impacts of telehealth on care quality and access to care, specifically: •
“Remote intensive care unit consultations likely reduce mortality.
•
Specialty telehealth consultations likely reduce patient time in the emergency department.
•
Telehealth consultations in emergency services likely reduce heart attack mortality.
•
Remote consultations for outpatient care likely improve access and clinical outcomes”. ¹
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Figure 2 Distribution of telemedicine, by WHO region ²
C. Traditional patient types served (pre-Covid): rural, emergency, and beyond
a. Telehealth used to be only about access; it is now also about convenience and cost
While telemedicine has traditionally been used most in rural care and in emergency care, even prior to Covid-19, there was an increasing use of telemedicine for outpatient care specialties like pediatrics and psychiatry, and, increasingly, “health-everywhere” applications, as for remote monitoring, home health, and kiosk-based health. According to WHO, radiology is the leading use of telemedicine. (Fig. 2)
c. Telehealth used to “live” in hospitals and satellite clinic; now it is also in homes and on mobile devices.
Apart from branching out in services provided, there was also an increase in the sheer preponderance of telemedicine: “Telemedicine use rose from 54 percent in 2014 to 71 percent in 2017, according to a survey conducted by the Healthcare Information and Management Systems Society’s HIMSS Analytics, and a February 2018 post by the Patient Safety & Quality Healthcare journal indicates that as of 2017, all 50 states have adopted some form of telemedicine reimbursement coverage.” ³
D. Covid-related changes to telemedicine: Better reimbursed and easier to do
According to an article in New England Journal of Medicine, three interlinked trends have been reshaping telehealth: ⁴
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b. Telehealth used to be focused on acute conditions; it is now also about episodic and chronic conditions
Telehealth is especially well accepted by organizations that both finance and deliver health care (e.g.., Kaiser, DoD, VA), indicating that where cost and quality both matter, it is an effective approach. (Fig. 3)
Regulatory changes have made it easier and more remunerative to deliver telehealth due to the national emergency of Covid-19. 1.
Reimbursement/Pay Parity With Covid-19, telemedicine became reimbursable under a broader range of circumstances. While it remains incumbent on providers to ascertain whether a telehealth visit is adequate or whether to “divert” to a face-to-face visit, the current environment gives providers the benefit of the doubt more than previously. ⁵
Figure 3
There is concern about scope for fraud in telemedicine, but, given national crises, debate or action on this is mostly on hold. ⁶ 2.
Common apps now acceptable for telemedicine, Many common, including phone-based, aps can be used. Providers are to warn patients of privacy risks and not use public-facing apps, like Facebook or Tik-Tok.
Some details from the U.S. Department of Health and Human Services: “Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules during the COVID-19 nationwide public health emergency. Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.” The changes in modality may seem trivial, but they could make a big difference to the feasibility of telemedicine. In a study of elderly patients, technical difficulty was an important barrier to telemedicine, with about half of patients failing to log into video-based telehealth programs. The patients who managed to access the video visits reported greater satisfaction with videobased visits than with phone-only visits. Further, patients can submit pictures or video to providers for diagnosis.
3.
The only environment-related stipulation is that providers use “private” settings (or at least try to)
Private environments are to be secured on both the patient and the provider side for telehealth, though exceptions seem to be expected. From the U.S. Department of Health and Human Services Office for Civil Rights: “Where can health care providers conduct telehealth? OCR expects health care providers will ordinarily conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic. Providers should always use private locations and patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances. If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPPA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speaker phone, or recommending that the patient move to a reasonable distance from others when discussing PHI.” 8 (Note on temporary relation of HIPPA: “Secretary Azar has announced that, effective March 15, 2020, a limited HIPAA waiver has is in place covering the following provisions of the HIPAA Privacy Rule: 1. The requirements to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care – 45 CFR 164.510(b), 2. The requirement to honor a request to opt out of the facility directory – 45 CFR 164.510(a); 3. The requirement to distribute a notice of privacy practices – 45 CFR 164.520; 4. The patient’s right to request privacy restrictions – 45 CFR 164.522(a); 5. The patient’s right to request confidential communications – 45 CFR 164.522(b)” 9
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II. EXISTING DESIGN STANDARDS A. FGI 2018 Guidelines on telemedicine for new construction and large renovations The guidelines include the following main points and are summarized in a slide deck called “Accommodation for telemedicine services”. 10 11, 12
telecommunication and in terms of flexibility of spaces used. For example, instead of creating a telemedicine room for orthopedics that is long enough to observe walks, patient presenters might move a device to an adequately private space to record movement. 2.
The main aim here is speech intelligibility, with strategies focused on quiet locations in the building, as well as consideration of sound isolation and background noise. On the technical side, they should be designed to minimum sound transmission class ratings with respect to all parts of the room envelope. (See general FGI guidance on acoustics.) Requirements may vary based on specific room function.
Telemedicine services require a bay, cubicle, or room that must be provided to accommodate those services. If telemedicine patient volumes are low, such a space can have a dual function. (Note, under Covid-19 conditions, the new business-as-usual is that telemedicine is frequently occurring from spaces designed for other functions.) 1.
Size of telemedicine spaces a.
For telemedicine, the space should be big enough that an exam table can fall in view of the camera with enough room for telemedicine equipment, devices, and the on-site caregiver or patient presenter, a hand-washing station, and a documentation area.
b.
There should be no way to see any monitors, screens, etc. from outside the telemedicine space (e.g., through side lights/windows or doors in use).
3.
4.
The locations of camera and exam table should work in a way that the presenter can at once perform the relevant tasks while still keeping visual contact with the patient and monitor.
d.
Put the microphone where it works for speaking, but also four feet or so from the workstation to reduce audio feedback.
5.
Pay attention to specialty when sizing and placing equipment; for orthopedics, it may be necessary to remotely see gait along a walkable area.
6.
COMMENT: These guidelines were created prior to the Covid-19-related supports for telemedicine. They may not make full use of the mobility and sophistication of 10 | BSA
Lighting a.
Recommendations are for a combination of frontal direct lighting supplemented with indirect lighting for image and color quality, using, specifically, “full-spectrum or warm, white light (3200-4000 K) with a minimum light level of 150 foot-candles”.
b.
Control glare and avoid seating arrangements that back-light telemedicine participants.
Interior surfaces See the guidelines or guideline summaries for details, but recommendations are for specific blues and greys. These are based on a single paper on digital medicine. Flat tones with specified ranges of reflectance for ceilings, floors, and walls are described.
c.
e.
Acoustics
Site identification The space or image should show where the care is taking place. Storage of equipment Solutions support the secure storage of telemedicine equipment, designing for infection prevention through clean-able arrangements, and arrangements that support eye-level communications.
III. FUTURES B. Some detailed considerations 13 1.
For telemedicine rooms, ensure outlet supply is adequate to avoid needing to bring in multiple power tab outlets (which The Joint Commission frowns on). Plan spaces and activities to prevent trip hazards.
2.
In addition to avoiding doors in view of the camera (for privacy), avoid doors behind patient to enhance patient sense of privacy.
3.
Place cameras to a near-even eye level.
Given the new incentives provided to practice telemedicine during Covid-19, we can expect some pushback against returning to the old normal. Prior to Covid-19, telemedicine was already increasingly seen as a way to improve population health by making care more accessible, affordable, and satisfying. There has been a post-Covid-19 telemedicine boom for some systems: •
Virtual visits at Partners HealthCare were 1,600 in February 2019 and 90,000 in March 2019.
•
InSight + Regroup, a telepsychiatry group, will advocate for keeping telehealth-promoting regulations in place beyond the current crises.
•
There may be a push to further reduce Medicare strictures on telehealth, for example, by allowing US-certified doctors living outside the US to practice remotely.
While telehealth may be in demand, apart from Covid-19, to increase convenience and improve cost and access, an enduring problem of telehealth is the lack of care providers being able to access vitals or other information from physical examination, especially if it involves specialized equipment or diagnoses by laboratory tests.
A. Programming and planning for telemedicine and telehealth FGI specifies the design of telemedicine rooms. However, telemedicine and telehealth take many forms outside of telemedicine rooms. Telemedicine can be centralized at a dedicated facility for telehealth providers (as at Mercy Health, see below), or it can be decentralized, with a single provider who works from home or an office. However, a number of cases indicate that telehealth is often provided as part of a hybrid work pattern: that is, by providers who do some care tasks in person and others through telemedicine.
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1.
Hybrid telemedicine can ease provider tasks at work by reducing travel, enabling rapid consult and, in for infectious cases, eliminating the need for all providers caring for a patient to undertake infection-control measures. a.
b.
c.
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2.
Telemedicine carts are highly useful in managing infectious patient cases. These carts, with cameras and telemedicine equipment, allow healthcare workers to present and assess patients under the guidance of physicians who stand nearby, checking in without coming to bedside. Physician rounding is not slowed by repeated doffing/donning. Per Dr. Todd Czartoski, chief medical technology officer at Providence, “We had people outside the room talking to the patient, evaluating them with the (electronic stethoscope) and keeping those communication lines open,” … “the hospitalists, infectious disease doctor and other specialists didn’t have to gown up and go in and out of the room multiple times a day.” Similarly, telemedicine-supporting features in fast-track exam rooms allow ER doctors to assist in increasing throughput safely and efficiently. If doctors can conduct telemedicine from their office for some patients, this approach has the potential to reduce time wasted on doctor travel. Academic medicine specialties, such as psychiatry, have used telehealth visits between patients, residents, and attending physicians. However, where formerly the resident and attending physicians would meet in a single space and contact the patient, currently, the attending physician can stay in his or her office, while the resident and patient call in from different locations. The attending and resident can use features of apps (e.g., Zoom) to hold any needed side conversations outside of patient hearing during the visit. Per an interview with an adolescent attending psychiatrist, this arrangement works as well or better than meeting in person with a resident to provide telehealth to a patient.
3.
Telehealth at home and elsewhere
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a.
Exam rooms can easily be equipped for telehealth. Putting aside FGI guidelines on interior finishes, what is mainly needed is a video display that includes a camera, microphone, and speaker functionality in conditions of adequate privacy. 18
b.
New York-Presbyterian is partnering with Walgreens with telehealth kiosks in eight pharmacies in New York City. (Fig. 4)
c.
Certain patient populations (e.g., Type 2 diabetes, post-operative) can participate in remote monitoring as a form of telehealth.
d.
Mobile stroke units have CT scanners and video capability for a remote neurologist to monitor and suggest in-field treatment.
e.
Telemedicine can also let physicians treat low-acuity patients at home through an ap or through a (Walgreen’s or similar) kiosk.
f.
Post-discharge patients can be sent home with devices for remote monitoring.
Centralized telemedicine. Perhaps, the most well-known centralized telemedicine organization is the Mercy Virtual Care Center (opened 2015, in Chesterfield, MO). The facility is 125,000 square feet and provides telehealth for Mercy’s 43 hospitals (in five states). It is recognized for integrating virtual services into a continuum of healthcare, and honing in on “accessible and affordable care opportunities”. It includes cross-programmed elements, such as an education center and think tank. 19
B. Potential metrics and methods of study The American Telehealth Association released, in 2020, A Quick-Start Guide to Telehealth During a Health Crisis. In it, the following are suggested as appropriate metrics for the success of a telehealth program, especially under quick-start conditions.
Figure 4 Walgreens-based kiosk operated with New YorkPresbyterian
“You can prove the value of virtual care using a variety of different metrics. However, for the quick transition to telehealth services that so many clinicians are now experiencing, the ATA Quick-Start Guide to Telehealth suggests four categories for a solid foundation to measure certain components of virtual care. 1.
By encounters – What is the volume of telehealth patient encounters? Understanding the volume helps gauge whether or not your deployed telehealth services work.
2.
By practice – Which practice groups successfully use telehealth services? Gauging what is successful, or not, by practice groups helps identify who is successful, a data point helpful in adding training resources.
3.
By number of cancellations and no-show rates – What is the number of cancellations and same-day no-show rates? Telehealth services and virtual visits often help reduce face-to-face cancellations and same-day no-shows. This is a valuable metric to follow.
4.
By diagnosis – Which services successfully use video visits? Monitor which services applied telehealth services looking at diagnosis data” 20
Because there is very little research on design for telemedicine per se, including these measures with Post-Occupancy Evaluation could help firms build initial insights on effective strategies and designs for telemedicine. During programming, the design team can work with clients to ascertain their goals with reference to the above organizational metrics, then bring in design and operational strategies aimed at achieving the aims. During post-occupancy, firms can conduct POEs that include end-user (care provider and/or patient) interviews and surveys and associate them with the metrics. This would form a basis for sound ideas about design features that promote successful telehealth and telemedicine.
C. Real estate downsizing Real estate downsizing due to a migration to telehealth is a possible future scenario. Such a scenario could be accelerated by the present situation in which a number of healthcare practices are threatened by permanent closure. 21 Larger systems may migrate more care to telemedicine beyond the pandemic. However, the current protelemedicine environment is directly linked to the national Covid-19 emergency, and the measures related to it have not been extended beyond the emergency.
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There is not yet much academic or industry literature related to how excess healthcare real estate may be adapted and used by systems that pivot to larger telemedicine practices.
D. National corporate leadership in telemedicine 1. White House-based resource: The White House and a number technology companies have set up a database of 57,000 articles on Covid-19 and other pandemic diseases 22 2. Google: Google’s efforts are currently mainly focused on enabling telecommunications. These include a focus on telemedicine-supportive apps. For example “…more people have been turning to Doctor Anywhere’s telemedicine services, and opting for video consultations with locally-registered doctors and medication delivered to their doorstep”. G Suite is also being used as a dashboard by hospitals especially in the United Kingdom, where “the NHS is exploring the use of G Suite to allow them to collect critical, real-time information on hospital responses to COVID-19, such as hospital occupancy levels, and accident and emergency capacity.” 23
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3. Amazon: a. In reporting 2020 second quarter Amazon earnings, CEO Jeff Bezos announced intent to improve worker conditions and develop Covid-19 testing: “Under normal circumstances, in this coming Q2, we’d expect to make some $4 billion or more in operating profit. But these aren’t normal circumstances. Instead, we expect to spend the entirety of that $4 billion, and perhaps a bit more, on COVID-related expenses getting products to customers and keeping employees safe. This includes investments in personal protective equipment, enhanced cleaning of our facilities, less efficient process paths that better allow for effective social distancing, higher wages for hourly teams, and hundreds of millions to develop our own COVID-19 testing capabilities.” 24 b. Amazon, Berkshire Hathaway and JP Morgan Chase set up a healthcare company about two years ago. The company was formed by these large employers in frustration with the cost and quality of care available through existing venues. A key exciting possibility of the company, called Haven, is that it could realize new efficiencies and even new diagnostic approaches by applying AI and advanced analytics to problems that were formerly considered to be mainly for human judgement.
So far, the main innovation offered by Amazon Haven is a telemedicine program for some Seattle-based employees. 25
2.
For psychiatry patients at home, it is important to have a trusted and designated care giver in the space. Should things begin to spiral out of control, this person would deliver the patient to safe care. All potential telemedicine patient types and practice areas should be carefully evaluated for similar or analogous potential vulnerabilities.
3.
Not all patients can be assumed to have the needed communications technology, especially economically disadvantaged patients. A Federal Communications observed “‘There’s actually an … unfortunate overlap between lack of broadband deployment in communities, low income, and poor health outcomes.” 30
4. Bill & Melinda Gates Foundation The Gates have supported telemedicine, largely for applications in the developing world, where smartphone use is becoming prevalent. Relative to Covid-19, they are focused on vaccine development. “…we are joining forces with Wellcome and Mastercard to beef up our response—backed by $125 million in both new funding and money already earmarked to tackle this epidemic. The money will be used to identify potential treatments for COVID-19, accelerate their development, and prepare for the manufacture of millions of doses for use worldwide. The expertise of pharmaceutical companies will be critical to this endeavor, named the COVID-19 Therapeutics Accelerator.” 26 5. Walmart Walmart, like Amazon, offers employees in some states a telemedicine program 27 6. Walgreens In addition to the collaboration with New YorkPresbyterian, Walgreens offers “MDLive”, a flat-fee ($75) telemedicine program between doctors and patients at home 28
1.
Absence of body language, context cues, availability of resources and equipment, and social milieu are all real losses. Designers who try to define “human connection” totally in terms of pleasant on-screen lighting, attractive camera angles, and the like are not being forthright with themselves or their clients. Being frank about limitations and trade-offs sets expectations appropriately and lays the groundwork for foreseeing and addressing problems.
However, related to a 2018 New Mexicobased initiative, telecommunications service providers have developed very low-bandwidth versions of apps, which may help expand access. 31
b.
In general, New Mexico has been progressive on telemedicine for rural health, which often involves disadvantaged patients. 32
4.
For some patients, including some elderly patients, health care visits are important to not becoming isolated at home.
5.
In the recent proliferation of telepresence for many jobs, workers have reported decreases in satisfaction with excessive (e.g., 15 or more) hours per week on telepresence calls. The questions of how to avoid provider burnout and how to support tacit learning for extensive telemedicine are not yet answered.
6.
There are some concerns about how telehealth bringing healthcare fully into the home “medicalizes life”. Rather than allowing medicalrelated anxieties to be compartmentalized, telehealth could render them unavoidable.
7.
As of 2016, the were a number of medical-system related barriers to telehealth as summarized in the table on the following page.
7. CVS CVS offers home-based video and in-person visits through its minute clinics, listing a flat fee of $59 29
E. Some warnings
a.
The recent regulations on reimbursement address some of these, but not all, and the table on the following page would be good points to discuss for programming and capital projects involving telehealth. BSA | 15
The recent regulations on reimbursement address some of these, but not all, and the below would be good points to discuss with clients considering building for telemedicine.
Figure 4 Limitations of Telehealth and Potenital Soultions
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Bibliography: 1.
From: https://effectivehealthcare.ahrq.gov/sites/default/ files/cer-216-telehealth-evidence-summary.pdf
2.
From: https://www.who.int/gho/goe/telehealth/en/
3.
From: https://www.hfmmagazine.com/articles/3337-fgilays-out-telemedicine-guidelines
4.
From: https://www.nejm.org/doi/full/10.1056/ NEJMra1601705
5.
From: https://www.cms.gov/newsroom/fact-sheets/ medicare-telemedicine-health-care-provider-fact-sheet
6.
From: https://www.hhs.gov/hipaa/for-professionals/ special-topics/emergency-preparedness/notificationenforcement-discretion-telehealth/index.html
7.
From: https://pubmed.ncbi.nlm.nih.gov/31348530/
8.
From: https://www.hhs.gov/hipaa/for-professionals/ faq/3021/where-can-health-care-providers-conducttelehealth/index.html
9.
From:. https://www.hipaajournal.com/hipaa-complianceand-covid-19-coronavirus/
10. From: https://www.fgiguidelines.org/wp-content/ uploads/2017/08/SLS17_FGI_Telemed_170721.pdf 11. From: FGI based their telemedicine guidelines on the following sources (links in Appendix): •
Papers by Janet Major (2005) and Elizabeth Krupinski (2014)
•
California Telemedicine and eHealth Center’s “Telemedicine Room Design: Program Guide” (2011)
•
Guidelines for telehealth rooms used by the Provincial Health Services Authority in Canada
•
American Telemedicine Association’s telemental health standards and guidelines (2009)
•
A consensus report in the Journal of Digital Imaging on consistency and standardization of color in medical imaging (2015)
12. From: For a summary article see: https://www. hfmmagazine.com/articles/3337-fgi-lays-outtelemedicine-guidelines?utm_medium=email&utm_ source=newsletter&utm_campaign=pdcnews&utm_ content=20180509&eid=371822167&bid=2095993 13. From: These details are outlined in the linked Center for Health video, from 19:12: https://www.healthdesign.org/ insights-solutions/telemedicine-where-we-are-and-whybuilt-environment-matters 14. From: https://www.modernhealthcare.com/technology/ coronavirus-fuels-explosive-growth-telehealth-andconcern-about-fraud?utm_source=modern-healthcarecovid-19-coverage&utm_medium=email&utm_ campaign=20200422&utm_content=article5-headline 15. From: https://www.modernhealthcare.com/patients/ new-telemedicine-strategies-help-hospitalsaddress-covid-19?utm_source=modern-healthcaredaily-dose-friday&utm_medium=email&utm_ campaign=20200306&utm_content=article5-readmore
16. From: https://www.vantagetcg.com/healthcare-designquestion-whats-the-impact-of-telehealth-on-the-designof-exam-rooms/ 17. From: Unless otherwise indicated, details at https://www.modernhealthcare.com/patients/ new-telemedicine-strategies-help-hospitalsaddress-covid-19?utm_source=modern-healthcaredaily-dose-friday&utm_medium=email&utm_ campaign=20200306&utm_content=article5-readmore 18. From: https://www.vantagetcg.com/healthcare-designquestion-whats-the-impact-of-telehealth-on-the-designof-exam-rooms/ 19. From: Virtual tour of Mercy Health available here: http:// www.virtually-anywhere.net/tours/mercy/mercyvirtual/ vtour/index.html 20.
Quoted text from: https://www.americantelemed.org/ industry-news/atas-quick-start-guide-to-telehealthduring-a-crisis/
21. From: https://www.medpagetoday.com/ infectiousdisease/covid19/85637 22. From: See: https://www.semanticscholar.org/cord19 23. From: https://cloud.google.com/blog/topics/insidegoogle-cloud/how-google-cloud-is-helping-duringcovid-19 24. From: https://www.marketwatch.com/story/amazonsceo-tells-investors-if-youre-shareowner-you-may-wantto-take-a-seat-as-he-explains-why-the-company-willspend-entirety-of-4-billion-profit-2020-04-30, and: https://www.nytimes.com/2018/01/30/technology/ amazon-berkshire-hathaway-jpmorgan-health-care.html 25.. From: https://www.fool.com/investing/2019/12/14/ amazon-continues-to-make-stealth-moves-into-health. aspx 26. From: https://www.gatesfoundation.org/TheOptimist/ Articles/coronavirus-mark-suzman-therapeutics 27. From: https://mhealthintelligence.com/news/walmartexpands-telehealth-services-for-employees-in-3-states 28. From: https://www.walgreens.com/findcare/mdlive 29. From: https://www.cvs.com/minuteclinic/virtual-care/ video-visit 30. From: https://www.americantelemed.org/industry-news/ fcc-commissioner-telehealth-push-is-designed-to-aidlow-income-americans/ 31. From: https://blog.zoom.us/wordpress/2018/01/23/ zoom-announces-support-for-full-enterprise-healthcareworkflows/ 32. From: https://nmpoliticalreport.com/2020/04/30/thegenie-is-out-of-the-bottle-rural-healthcare-providerssee-silver-lining-to-pandemic/ 33. From: https://www.nejm.org/doi/full/10.1056/ NEJMra1601705
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Appendix: Documents cited in FGI telehealth guidelines http://www.phsa.ca/Documents/Telehealth/TH_Room_ Preparation_Guidelines_TR.pdf http://www.cssspnql.com/docs/default-source/centrede-documentation/doc_telesante_salle_eng_web. pdf?sfvrsn=2 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4934495/ https://journals.sagepub.com/doi/ abs/10.1177/1357633X0501100103 https://www.ncbi.nlm.nih.gov/pubmed/25005868 rev: May 29, 2020
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Contact:
Timothy J. Spence, AIA, ACHA, LEED AP BD+C National Healing Market Leader 919.740.4649 tspence@bsalifestructures.com
