The Health Resources and Services Administration defines telehealth as
the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include video conferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.1
Telehealth can be synchronous (live/interactive) or asynchronous (delayed time between provider input and patient receipt, such as a radiological image sent to a remote provider). Telehealth can be delivered by a solo provider, or a telepresenter can augment a patient’s visit with, for example, a physician assistant, nurse, or technician, who performs an initial examination and facilitates communication between the patient and the telepresenter.
Telehealth has been available in various forms since the 1920s, but modern telehealth began roughly 20 years ago around the turn of the 21st century. Recent increased interest in telehealth reflects technical refinements (including widespread availability of smartphones); surveys indicating high patient and provider satisfaction; cost and time savings for patients; and studies suggesting that telehealth care yields equal or better health outcomes for selected conditions compared with in-person care.2 The Department of Health and Human Services estimated in 2016 that more than 60% of all health care institutions and 40% to 50% of all U.S. hospitals use some form of telehealth.3 Venture capital funding in digital health reached $4.3 billion in 2015.4,5
Telehealth is widely used in the Department of Veterans Affairs, where over two million telehealth encounters were conducted in 2017.6 Telehealth is poised to expand significantly in the Military Health System, which was a pioneer of telehealth use in austere environments such as combat zones. The 2017 National Defense Authorization Act (NDAA) directs, in part, that the full range of telehealth services be made available in the direct care and purchased care components in the Military Health System.6
One of the biggest barriers to telehealth adoption is lack of physician training. A 2017 survey of 4,980 family physicians revealed that, despite their stated interest, only 15% of respondents reported using telehealth; 55% cited “lack of training on how to use telehealth” (OR, 1.61; 95% CI, 1.18–2.18) as their reason for not using telehealth.7 The American Medical Association (AMA) has called for telehealth to become a core competency of medical students. The AMA has urged the U.S. House of Representatives to embrace telehealth broadly to ameliorate provider shortages, increase access to health care, and lower costs of reaching patients in remote settings.8
A literature search reveals telehealth courses teaching communication skills to medical students.9 However, no comprehensive curriculum for a telehealth course has been published in the United States. Based on the needs, observations, and favorable outcomes of telehealth outlined above, the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences (USU) designed, administered, and evaluated an Introduction to Telehealth course in February 2018.
Between February 2017 and February 2018, our nine-hour course was developed in close partnership with telehealth educational design and curriculum development experts at the Connected Health branch of the Defense Health Agency. In February 2018, the program was delivered in collaboration with interprofessional representatives from five government institutions and a civilian university in Maryland and Virginia: USU, Connected Health at the Defense Health Agency, Walter Reed National Military Medical Center, Fort Belvoir Community Hospital, the Daniel K. Inouye Graduate School of Nursing, and Old Dominion University. Faculty included seven family medicine physicians, one critical care physician, one doctor of optometry, three psychologists, four doctor nurse practitioners, one registered nurse, and eight information technology support staff. Evaluation was completed one week after course completion.
This required course specifically requested by the USU dean’s office was piloted in February 2018 with 149 third-year medical students who had just completed core clinical clerkships. The telehealth course filled space in the curriculum previously occupied by an elective course. Course objectives were to (1) use commercial off-the-shelf and military-specific technologies to teach telehealth, (2) expose students to current military telehealth equipment and applications, (3) practice faculty-supervised mock telehealth encounters via videoconference, (4) leverage technology to teach and prepare medical students to independently deliver telehealth, and (5) respond to calls by the AMA and the NDAA to improve provider comfort and proficiency with telehealth.
This learner-centered course directly engaged students, taught explicit skill sets, encouraged reflection on learning, and prompted learners to pursue control and collaboration in their learning during mock encounters. Training consisted of six segments consistent with Kern’s10 approach to curricular development: (1) a 21-question, required multiple-choice pretest delivered one week prior to the course; (2) four hours of asynchronous, interactive, graphics-rich lectures covering telehealth history, applications, ethics, safety, military uses, etiquette, and patient considerations; (3) three hours of in-person interactive telehealth instruction, including ethics, patient selection, current uses, risk management, and telehealth etiquette; (4) two standardized, faculty-supervised 30-minute mock patient encounters by way of videoconference; (5) hands-on operational experience where students practiced diagnosing common maladies and practicing advanced surgical procedures via telehealth using military telehealth equipment; and (6) a 21-question, required multiple-choice posttest and course evaluation completed within one week post course. Pre- and posttest questions (see Supplemental Digital Appendix 1, available at https://links.lww.com/ACADMED/A652) were identical; blueprinted to course goals and curriculum; and relevant to mock encounters, lectures, and classroom interactions. Checklists were used to assess for success in mock encounters and completion of course objectives (Appendix 1). The Uniformed Services University Institutional Review Board (IRB)/Human Research Protections Office reviewed the course and determined that it does not constitute research and does not require IRB review.
To avoid monotony, we used three different approaches to education throughout the course: asynchronous instruction, classroom interaction, and mock patient encounters.
An interprofessional panel of telehealth experts selected and created asynchronous materials deemed essential for conducting a telehealth encounter. Before the course day, students were advised to view four hours of online materials presented in written and PowerPoint formats covering important topics, including history and rationale for telehealth, telehealth etiquette, mental health aspects, patient selection, applications, advantages, disadvantages, patient perceptions, physician beliefs, current military and civilian care, applicable legislation, NDAA, Government Accountability Office, doctor–patient relationships, human factors, ethics, safety, and use of lighting. This self-paced material was designed to impart basic knowledge of telehealth for students prior to entering the classroom in hopes of optimizing engagement and preparation for mock encounters. Students were informed that they would be expected to recall and use this information during mock telehealth encounters and posttesting; however, student participation in the asynchronous portion was not monitored.
The lecture portion of the course was taught using traditional large-classroom instruction with audience participation. Information covered in these sessions focused on ethics and risk management, proper etiquette, lighting, camera angles, clothing selection, telepresentation skills, and technical skills needed for successful video-based encounters. Case vignettes, examples of good and bad telehealth encounters, physician attitudes, experiences, current facilities providing telehealth, and operational and clinical pitfalls were also discussed. At various points, students were asked to respond to online polling questions using their mobile devices as well as traditional verbal question-and-answer sessions. Many questions probed student attitudes about, experiences with, and plans to practice telehealth. A dedicated section on military telehealth was taught by critical care professionals who currently provide telehealth globally in support of deployed providers and service members. Students were given faculty-supervised dedicated time during the course and elective time to practice advanced diagnostic and surgical treatments using military telehealth ear, nose, throat, surgical, and trauma equipment on mannequins.
Mock patient encounters
Students were assigned to small groups of four, and faculty provided instructions on how to conduct a history and physical via videoconference (Table 1). Other students who role-played patients were provided written scripts for one of two cases (see Supplemental Digital Appendixes 2 and 3, available at https://links.lww.com/ACADMED/A652). The first case was a common varicella skin rash, while the second was a complicated patient with diabetes and potential medication-induced mania. Cases were selected reflecting two common uses of telehealth in the Military Health System: tele-dermatology and tele-behavioral health; neither posed significant physical exam requirements. Both cases were overseen by faculty members who facilitated the student-to-student encounters and who had attended a 60-minute training session prior to the course. Checklists that had been created by an interdisciplinary panel of telehealth experts as unique products believed to be essential to conducting a proper telehealth encounter were used to assess proficiency. These checklists were used both by fellow medical student observers and by faculty in rating all 149 (100%) students who led mock patient encounters. After each case, faculty and students provided “patient” feedback emphasizing precourse principles and lecture materials, and verified on checklists (Appendix 1). Technology failures were minimal.
Students increased their overall telehealth knowledge, which was demonstrated in several ways: (1) a 10.1% average improvement between pre- and posttest scores (mean pretest score: 13.76 [SD 1.95]; mean posttest score: 15.89 [SD 2.67]); (2) successful completion of all checklist tasks; and (3) postcourse preceptor and student feedback. Faculty and students felt that, in contrast to a traditional lecture-based format, the mixed-methods course design and simulated telehealth encounters were novel and engaging. Faculty and students expressed enjoyment with telehealth mock encounters and cases, and checklists were effective in focusing these exercises, highlighting specific points, and standardizing educational experiences. Students and faculty suggested increasing practice with military diagnostic and procedural equipment in future courses.
Among participating students, 80% (119) indicated plans to provide telehealth in the future. Several requested to be part of future courses or electives about telehealth. The hands-on practice using advanced operational equipment, such as augmented reality headsets, was very popular and effective. Having the full support and direction from the USU dean’s office was unique and crucial in terms of selecting the most appropriate space, substance, and execution of this course. There were no drawbacks from having that support and direction.
Every study has limitations; this one is no exception. Our observations are based on the first teaching of the course to a single class of medical students who attend a medical school with a unique, national service mission. The 10.1% increase in knowledge between pre- and posttest responses is relatively modest for the time invested, but checklist assessments of students’ performance documented acquisition and application of skills. Space and time considerations did not allow for as much student participation in telehealth delivery as students wanted. Nevertheless, interest and acceptance were high. Because we found no other published curricula to introduce medical students to telehealth, we could not compare our approach against others. Publication of other curricula and subsequent comparison will be crucial to assess true effectiveness of telehealth education. We welcome collaboration with interested institutions.
The short course we developed is designed to serve as a baseline introduction to telehealth for USU medical students. Future plans include telehealth integration in field training exercises, core clerkships, and clinical electives. Nationally, core principles and methods from this course may be adopted by other medical schools to teach their students.
Future iterations should focus on student participation in supervised mock encounters via videoconference and maximizing use of telehealth technologies, including diagnostic and procedural equipment. We found that this methodology was more popular than other means of instruction, so we will expand it in future courses. We may also add telehealth practice with standardized patients in our Simulation Center. Additionally, assessing student interest in telehealth before and after the course, expanding pre- and posttesting, and monitoring participation in asynchronous instruction should prove useful.
Incorporating standardized patients and monitoring student participation will be key enhancements. In the first iteration of this course, students served as mock patients and monitored their own participation in asynchronous instruction because of space and time considerations. A next step would be the potential testing with standardized patients in a 1:1:1 (patient:telepresenter:student) training model with faculty oversight. The ultimate test will be to assess patient experiences between those trained in this method and those either trained in another method or not at all. With that comparison, a more ideal telehealth educational platform can be created and implemented. Our goal is to share our own lessons learned and collaborate with other institutions in improving telehealth education and ultimately patient care nationally.
This course represents a potential first step in teaching medical students comprehensive telehealth in the United States. Although elements of our curriculum included military-specific content, the vast majority of instruction focused on basic principles of telehealth delivery in synchronous and asynchronous applications. It could be worthwhile to remove military-specific portions of this course and pilot the remaining portions in any U.S. medical school to assess interest and impact and to estimate generalizability.
Because today’s medical students have grown up using computers, video games, and smartphones, we feel it is essential to emphasize differences between medical and personal uses of communication technologies. The former requires training in appropriate principles and standards for health care delivery, including patient privacy and information security. It is important to note that throughout the course, students reported that they are already using personal communications technology in health care capacities and settings without formal training. This finding underscores the importance of foundational training in appropriate use of telehealth to every student at an early point in training. Otherwise, there is a significant risk of serious missteps in patient care or medical ethics.
Acknowledgments: The authors would like to acknowledge Arthur L. Kellermann, MD, MPH, Rachel Wein, Gustavo Benitez, and Odine Doore for their support in the creation and execution of this course.
1. United States Health Resources & Services Administration. Telehealth programs. https://www.hrsa.gov/rural-health/telehealth/index.html
. Accessed March 5, 2019.
2. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375:154161.
3. Office of the Assistant Secretary for Planning and Evaluation. Report to Congress: E-health and Telemedicine. August 19, 2016. Washington, DC: U.S. Department of Health and Human Services; https://aspe.hhs.gov/pdf-report/report-congress-e-health-and-telemedicine
. Accessed March 5, 2019.
4. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377:15851592.
5. Wang T, King E, Perman M, Tecco H. Digital health funding: 2015 year in review. Rock Health website. https://rockhealth.com/reports/digital-health-funding-2015-year-in-review
. Published 2016. Accessed March 5, 2019.
6. Department of Defense. National Defense Authorization Act for Fiscal Year 2017: Section 718. https://www.congress.gov/114/plaws/publ328/PLAW-114publ328.pdf
. Published December 23, 2016. Accessed March 5, 2019.
7. Moore MA, Coffman M, Jetty A, Klink K, Petterson S, Bazemore A. Family physicians report considerable interest in, but limited use of, telehealth services. J Am Board Fam Med. 2017;30:320330.
8. American Medical Association. Statement of the American Medical Association to the House Committee on Energy and Commerce Subcommittee on Health, RE: Telemedicine. https://searchlf.ama-assn.org/letter/documentDownload?uri=/unstructured/binary/letter/LETTERS/statement-sfr-telemedicine-congressional-review.pdf
. Published May 1, 2014. Accessed March 5, 2019.
9. Liu C, Lim RL, McCabe KL, Taylor S, Calvo RA. A web-based telehealth training platform incorporating automated nonverbal behavior feedback for teaching communication skills to medical students: A randomized crossover study. J Med Internet Res. 2016;18:e246.
10. Kern DE. Curriculum Development for Medical Education: A Six Step Approach. 1998.Baltimore, MD: Johns Hopkins University Press.
Appendix 1 Checklist for Students and Faculty Observing Third-Year Medical Students Completing a Videoconference-Based Telehealth History and Physical During a Required Telehealth Pilot Course, Uniformed Services University for the Health Sciences, 2018