TELEHEALTH

Maximizing Telemedicine Benefits

Establishing work flow integration

BY ELIZABETH A. KRUPINSKI, PHD

The United States and the world have seen a dramatic increase in the use of telemedicine since the inception of the COVID-19 public health emergency, due in most part to stay at home restrictions for both providers and patients. Prior to this, telemedicine was used in a wide variety of clinical and related patient care applications for at least 30 years, and had been seeing steady but not exponential growth. With the onset of the pandemic, in many cases programs were initiated quite rapidly using readily available and often low-cost equipment and tools, unless there was already an existing program and platform in place. The rapid uptake of telemedicine was facilitated at the state and federal levels by widespread waivers and measures to reduce barriers that were previously in place such as changes in reimbursements, requirements regarding patient and provider locations, cross-state licensure and privacy/security requirements. Those of us who have been in the field for a long time are hopeful that many of these measures will stay in place, but there are clearly some that will or already have expired. We are additionally hopeful that even though in-person practices are clearly coming back full-tilt, that everyone has seen and/or experienced the benefits of telemedicine and will continue to use it to some degree as feasible and appropriate with their patients.

Moving forward, providers will be faced with new challenges as they transition their pandemic generated telemedicine process to a new world of hybrid services. As noted, some things will still be allowed (e.g., certain billing codes) but others will likely return to pre-COVID status (e.g., use non-HIPAA-compliant devices and software platforms). In addition to finding the best software for future telemedicine applications, there are other things to consider when trying to maximize telemedicine benefits. From my perspective, although the technology is critical, telemedicine success has very little to do with the technology and everything to do with the people and the environment within which they practice. Thus, in order to maximize telemedicine, what follows are elements one should consider and focus on in addition to carefully selecting the most appropriate technology for your practice and providers.

Success requires planning

First and foremost, the key to a successful telemedicine program is planning and figuring out exactly what role you expect telemedicine to play and how it fits in the mission and goals of your practice or institution. The use cases need to be clearly defined and must match an identified need. Then the who, what, where, why and when must be carefully delineated. Who needs to be involved (e.g., providers, billing, scheduling, IT, legal, administration), what clinical tasks can be accomplished via telemedicine, where will the technology and/or providers be located (e.g., clinic, home), where will the patients be (e.g., primary care provider office, home, work, school), why will telemedicine be offered as an option (e.g., lack of sub-specialty providers, patients need to travel long distances, no show rates are too high) and when will telemedicine be offered (e.g., certain days/times, any opening in the schedule)? All of this can be accomplished by plotting out in a workflow diagram what the current practice is and how it needs to be adjusted in order to integrate telemedicine into that workflow. Again, the expectation is that although some practices might remain essentially virtual, the majority are going to evolve into a hybrid practice – but such a hybrid will not happen overnight or automatically. Workflow integration is going to be just as critical as integrating telemedicine technologies into a practice – it really is all about the people, setting expectations and establishing standard operating procedures and protocols for everyone who is going to be involved.

Another thing that can be done to maximize a telemedicine practice is to properly train everyone involved on standard operating procedures and protocols, especially the providers who will be interacting with the patients. Currently there are only a few states (e.g., Washington) that require providers to be trained in order to provide telemedicine services and oversee at the compliance aspect. For the most part training requirements are at the institutional level and are overseen by some sort of telemedicine oversight committee. For example, at Emory University a training program was developed by the Virtual Care Executive Team and all providers engaged in telemedicine are required to complete the on-line course before interacting with patients. It will be interesting to see what happens in the future as programs become more established. It is possible that insurance

companies could start requiring and tracking training, as could the various medical boards. To date, however, there are no unified efforts on the near horizon so training and compliance will likely remain at the organizational level at least for now.

To date there are very few training programs that formally incorporate telemedicine as part of the curriculum. A number of programs are increasingly exposing trainees to telemedicine if offered at their institution, but typically as an elective or chance encounter in the clinic. There are very few that require any sort of formal training in telemedicine, although this is very likely to change within the next few years as institutions evaluate their curricula and become aware of the need to train the next generations of providers in telemedicine. Success has very little to do with the technology and everything to do with the people.

AAMC proposes telehealth core competencies

There are a number of organizations that are working on developing and promoting telemedicine standards and one of them, the Association of American Medical Colleges (AAMC), recently developed a set of Core Competencies. Although specific to medical college trainees, they are comprehensive enough to cover nearly every other specialty/profession in many respects.

Very briefly, the AAMC Telehealth Competencies consist of three tiers each with a set of explicit skills that increase in complexity and responsibility across three stages of practice: entering residency, entering practice and experienced faculty physician. The skills from each prior stage of training should carry over to the next phase as the provider becomes more expert and acquires additional skill sets.

The competencies are organized across the following six domains: patient safety and appropriate use of telehealth, access and equity in telehealth, communication via telehealth, data collection and assessment via telehealth, technology for telehealth; and ethical practices and legal requirements for telehealth. Patient safety and appropriate use of telehealth includes four skill sets ranging from being able to explain to patients and caregivers the benefits and limitations of telemedicine to knowing when a patient is at risk and how/when to escalate care (e.g., convert to in-person) during an encounter. Access and equity in telehealth has three skill sets, including knowing your biases and implications when considering healthcare, how telehealth can mitigate or amplify access to care gaps, and taking into account all potential cultural, social, physical and other factors when considering telemedicine. Communication via telehealth has three skills covering establishing rapport with patients, creating the right environment (e.g., lighting, sound) and knowing how to incorporate a patient’s social support into an encounter. Data collection and assessment via telehealth covers how to obtain a patient history, how to conduct an appropriate remote exam, and how to deal with patient-generated data. Technology for telehealth does not expect everyone to be an engineer or IT expert, but they should be able to explain equipment requirements for a visit, explain limitations and minimum requirements, and explain risks of technology failure and how to respond to them. Ethical practices and legal requirements for telehealth similarly do not expect everyone to be a lawyer but they should be able to describe local legal and privacy regulations, define components of informed consent, understand ethical challenges and professional requirements and assess potential conflicts of interest (e.g., interest in commercial products/services). Many of these skills can be acquired by those already in practice through attending the wide variety of courses and webinars available for telemedicine skill building. It is also highly recommended that before engaging with patients for the first time via telemedicine to engage in some simulated practice sessions – from start to finish practicing each skill and developing your “style” for interacting with patients via this virtual medium.

Assessing your program

Finally, in order to maximize benefits you need to assess your program. This does not require a degree in statistics or setting up a complex experimental study. It really requires just two things – a set of metrics and a process. There are lots of metrics available and most have been studied in a wide variety of clinical applications so a good lit review will always help get you started. It is important to keep in mind that the things you measure need

Maximizing Telemedicine Benefits to page 184

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to reflect your goals/mission for using telemedicine, the bottom line of making a profit is not always the most appropriate metric to use. There are many relevant metrics and a good starting place is the article by Shore et al. “A lexicon of assessment and outcome measures for telemental health” is a great source to get some ideas. Although developed for the telemental health community, the metrics provided apply quite well to nearly any specialty or practice. The metrics include such things as patient/provider satisfaction, no shows, symptom outcomes, completion of treatment, wait times, number of services, cultural access, cost avoidance and patient safety. Once you decide on metrics that are appropriate for your practice (recommend starting with 2-3, then add more as your practice grows) there is a very easy, straight-forward process for getting to outcomes. First, consider a given measure an indicator – these are concrete activities, products, etc., that can be measured readily (e.g., from the patient record). For example, you could measure A1C levels in patients as a function of being enrolled in a telenutrition program. The next step is to set performance targets – these are concrete goals that are time limited and based on the indicator metrics. For example, you would like to see a 25% reduction in A1C levels in at least 50% of patients enrolled in the telenutrition course at six months post-baseline. Finally, you will have quantifiable outcomes (without fancy statistics) at the end of your set time period – if you meet your 25% reduction goal in 50% of patients, great. If not, then maybe reassess the program or whether your goals were realistic. In any case, you now have concrete outcomes of your program demonstrating its benefits that you can provide to funders, administration, your care team and even patients and the community. In order to maximize telemedicine benefits you need to get the word out about its availability and its effectiveness!

Looking forward

The world has changed for physicians and whether you are a solo practitioner, in a small independent practice, or part of a large heath system, whether rural or metro or specialist or generalist, we will all be increasingly impacted by telehealth. As best practice guidelines are developed and integrated we have an opportunity to help shape that future. The nature of telehealth is very collaboration-friendly and the opportunities it presents for improved outcomes (and lower costs) are significant. It can and will shape medical decision making and it is up to us all to be sure it is done in the most positive ways.

Elizabeth A. Krupinski, PhD, FSPIE, FSIIM, FATA, FAIMBE, is Professor

and Vice-Chair of Research at Emory University in the Department of Radiology. She is Associate Director of Evaluation for the Arizona Telemedicine Program and Co-Director of the Southwest Telehealth Resource Center. She is Past President of American Telemedicine Association, Past Chair of Society for Imaging Informatics in Medicine, and President of the Medical Image Perception Society. She is Editor of Telemedicine Reports.

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