Elements of a Successful Telehealth Visit

There are two common objections we hear when discussing adoption of telemedicine as part of a clinical practice.

The first is that the doctor and the rest of the clinical team are unfamiliar with video conferencing, which is, of course, a primary component of synchronous telehealth visits.

The second is that their particular clinical workflows won’t support telemedicine. One typical concern is that the doctor or midlevel provider is unsure how they will be able to diagnose without physically touching or having the patient in the same room.

The answer to both of these objections is that this year there will be between 35 and 42 million telehealth visits in every specialty imaginable. It’s clear that what appears to be barriers to telehealth are in fact, just speed bumps. These perceptions are being swept away as the convenience and efficiencies of the virtual visit are widely embraced by doctors and their patients.

So, what are some best practices for clinical success during the telehealth visit? How can doctors – especially orthopedic specialists – use telemedicine to improve patient outcomes while lowering costs?

Telehealth requires a change in clinical workflows. There are the obvious differences in the clinical exam being conducted via video screens. There are less obvious challenges tied to trust and rapport during a virtual visit. But because telemedicine has been practiced since the 50s, we know a thing or two about creating the perfect virtual visit.

One mistake that can be made by a hospital implementing a telehealth service line is the assumption that doctors and midlevel’s will automatically understand the best way to conduct the visit. The first consideration is for the technology itself; the clinical team must be trained in how to use these tools.

Some of the tips we provide to our clients include:

• Step one is to ensure a high-quality telemedicine service, Internet connectivity, and webcam to conduct the visit.
• The telehealth tools used for the encounter should be set up roughly 10-minutes before the visit, in the same way that an exam room is prepped.
• Protocols should be established and practiced in the event the technology fails on either end of the visit.
• Make sure the webcam is at eye level. Eye contact is an important part of any clinical visit, and this can be accomplished easily during the virtual visit.
• Many times the camera is pointed up at the doctor, distorting the connection. Try sitting back from the camera while keeping the video stream as level as possible.
• Avoid having overhead lights behind the person, which will darken their face.
• Make sure you have a quiet space for these visits, with no interruptions. Even if these visits are conducted from home, clinicians should always wear professional attire.

Next, we train clinical teams by providing them with some of the typical clinical protocols we recommend they adopt, including:

• A telemedicine consent form should be signed prior to the visit.
• All telemedicine staff must be trained in the proper use of the video equipment or other tools.
• To ensure confidentiality, a private room with a closed door is required.
• Full disclosure must be made at the beginning of the encounter. This includes making the patient aware of everyone in the room, including anyone off camera.
• The clinician(s) must introduce themselves at the start of the visit and provide their credentials. This will help engage the patient in his or her own care.
• The clinician should also greet the patient by name, to help establish identity — and rapport.
• If the patient appears confused or uncomfortable with the virtual visit, always offer to reschedule the visit on-site at your office.
• At the conclusion of the virtual visit, the clinician must discuss the treatment plan with both the nurse or midlevel and the patient.
• All documentation must be completed at the conclusion of the visit.

But what about the actual clinical diagnosis? How can a clinician learn enough to actually diagnose a patient when they aren’t even in the room?

It’s important to note that the telehealth visit follows the same clinical guidelines as any visit, namely, a thorough history and a series of questions along with a visual examination. We all know the value of the series of questions documented via the patient history – 95% of the diagnosis comes from the history, according to Osler.

Yet the video visit does provide us with an effective way to examine patients. For example, a telehealth visit can show you:

• Whether a patient is sitting up or lying down.
• Skin tone, capillary refill, skin lesions, scars, and so on.
• The rate of respiration.
• Clarity of speech and cognition.
• Gait.
• Wound healing, atrophy, and asymmetry.

Orthopedists can ask patients to show range of motion or move their joints and assess pain levels. The patient can move the camera or smartphone to show certain body parts, or even take their own temperature or pulse while we time them. A bathroom mirror can greatly enhance field of view. We’ve even seen doctors instruct family members on how to press on an abdomen to assess for appendicitis.

Telemedicine Magazine lists some common ailments and shows how telemedicine can be used to make the diagnosis:

• Ankle pain
  Use the Ottawa Ankle Rules and evaluate whether they can bear weight. Instruct a family member on how to palpate the area.
• Conjunctivitis
  Seeing the eye on video to access symmetry, icterus, injection, and ocular movement. You can check visual acuity with an eye chart via a smartphone download. The patient can even use a flashlight to establish reactivity.
• Pharyngitis
  The patient can angle their smartphone flashlight to show the tonsils while facing a desktop camera. Instruct the patient to feel for tenderness over the lymph nodes. Is their nose runny or are they coughing?

These are just three simple examples, but there is ample clinical research showing the efficacy of clinical exams in virtual models.

However, it’s important to empower the clinician to use their judgment and discretion in making the diagnosis. If the physician doesn’t feel they can appropriately provide a diagnosis, they should triage the patient for an in-person visit.

Ironically, in some ways, clinicians give up a little control during the telehealth visit. An article in mHealth Intelligence put it this way:

With an in-person consult, the doctor is more in charge, an authority figure in his or her own environment. But with telehealth, the doctor is stepping into the patient’s environment.

We believe that telehealth actually is an important part of population health initiatives. The telemedicine visit empowers patients in their healthcare and engages them in new ways. Clinical studies have shown these visits to improve outcomes and cut costs.

To discuss adopting a telehealth service line, contact us.