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Feature: COVID-19 AND TELEHEALTH SERIES

COVID-19 and telehealth

Applying telehealth and telemedicine in a pandemic

Adelman, Deborah S. PhD, RN, NE-BC; Fant, Catherine PhD, RN-BC; Summer, Georgianne DNP, RN, AGACNP-BC

Author Information
doi: 10.1097/01.NPR.0000737200.56057.2c
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The first article of this three-part series introduced telehealth technology and its various modalities, and described the impetus for telehealth through legislation and its rapid uptake during the pandemic, as well as its benefits and challenges.

Considering the present use of telehealth and telemedicine during the pandemic and possibilities for their continued use in the future, how the NP approaches their use in their practice must be carefully examined. The need for patient education and training can be seen in the example of one of the authors of this article. She is very conversant and comfortable using technology, but was apprehensive during her first telehealth visit with her healthcare provider. No explanation of how to use the telehealth technology was provided to her besides a link. When the healthcare provider did not show up for a half hour following the appointment time, the author was unable to find a way to contact anyone at the clinic site to check if there was an error in date or time. When she called the clinic, she was directed to a recording requesting her to stay on the line as they were busy. As the author was about to hang up after waiting a further 10 minutes on hold, the physician appeared. She apologized for the delay explaining she was busy with other patients, and went right into the new patient visit. Not a good initiation to telehealth. What should and could have been done to make the encounter positive for both the provider and the patient? This article will address what the NP needs to know to use telemedicine and telehealth technologies and how to help their patients in using the technologies.

Education of stakeholders

Patients and healthcare providers need education regarding telehealth's benefits, ways to participate in a visit, and methods to use the technology. For both, the technical aspects may present the most challenges. Depending on a platform purchased from a vendor or through a healthcare organization may or may not offer the provider an optimal experience.1 Patients may experience issues with insufficient or nonexistent broadband. Unfortunately, broadband and even reliable broadband does not exist for everyone.2 There may be cost issues for both the provider and patient, such as the cost of a telehealth platform for the provider and information communication tools for the patient.3 Until recently, both providers and patients had voiced concerns about the quality of the interaction, especially as it compared with face-to-face encounters. Now however, this attitude is changing.4 A virtual visit should be treated the same as a face-to-face visit with all attention focused on the patient.

The telehealth environment is very different from in-person interactions that are so traditional in healthcare. Training of staff in this new environment presents new challenges. In-person encounters allow both individuals to have a clear view of each other and the surrounding environment, responding to verbal and nonverbal behaviors, and engaging in other senses beyond visual and auditory. Whereas, the telehealth environment is much smaller, as is the view of each person in the encounter. However, patients are still able to respond to visual and auditory cues. Depending on the technology used, the viewing area may be as small as a 6.1-in iPhone X or a 14-in monitor on a laptop. One positive aspect of a telehealth visit, unlike in-person visits, is the ability of the provider to see the patient's home environment, if the person is at home.5

While licensing and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) waivers temporarily enable providers to practice with fewer constraints during the pandemic, new issues and challenges still arise. Having the technical aspects of the visit well thought out and arranged before the visit will help to ensure a positive experience for both the provider and patient. How one presents oneself professionally during a video-conference is as important as having the technical aspects under control. These include setting the tone of the visit in a positive manner, and demonstrating through good eye contact and tone of voice that the visit is as important as a face-to-face visit, thus gaining the patient's confidence.5

Staff education

The actual training of staff can be supported by resources that include training modules, webinars, and teleconferencing and certification programs from Telehealth Resource Centers, all of which can be done asynchronously. Vendors of telehealth platforms offer training programs at no cost to healthcare organizations. As with any new technology training, individual superusers are an important resource on site for staff. As with implementing any new technology, practice testing may be required to ensure seamless functioning.7

It is important for the provider to determine how to convey empathy and establish trust with the patient during a telehealth visit. Healthcare providers need to develop “on-line manners” and use communication skills that complement this technology. Patients still need to feel like they are being listened to and their needs are being understood. Consequently, there is greater satisfaction from the interaction when the healthcare provider attends to one's appearance, prepares for the encounters, and rethinks one's communication skills in light of this new environment. To ensure that the NP and patient are satisfied, it is important to keep in mind the following telemedicine “etiquette” tips.

  1. Use high-quality equipment–Depending on if the provider is in private practice or part of large organization, there may or may not be an ability to choose this. If the provider is able to choose the equipment, use top quality webcams and sound equipment; this allows for a better patient experience and higher satisfaction with the visit, and reduces the risk of equipment failures.8 Provide feedback to the information technology staff about specific equipment issues, so that proper support can be offered.
  2. Dress and behave professionally–Wear lab coats when appropriate and always display the appropriate ID badge. Dress appropriately; the color and pattern of your clothing and jewelry selection (if worn) should be considered, as some patterns cause odd effects on a webcam. It is important to inform the patient that the area in which you are conducting the visit is private and secure. Moving the camera around the room can show the patient it is secure.8,9
  3. Be punctual–Patients appreciate/value providers being on time. Your system can be set up to notify you when the next patient is available and to notify patients that there may be unexpected delays with an explanation of what to do if the wait is at a point where the patient needs to leave the visit.9
  4. Create professional space–Check the space prior to the visit to ensure it is ready for the encounter. The space needs to be clean and quiet. Sitting at a desk is optimal. Make sure there are no noises or distractions. The door to the space needs to be kept closed with a sign stating “Patient Visit in Process”. Do not move paper around or make distracting noises. If external noise cannot be minimized, explain its sources to the patient. Avoid having others present, if not needed for the visit, but, if there are other people present during the visit, ensure there are no side conversations and introduce any other people in the room.8,9
  5. Thoroughly review the patient's reason for the visit–A better understanding of the reason for the visit will result in a more productive and satisfying visit for both parties.8,9 A new initiative, OurNotes—that has developed out of OpenNotes encourages patients to provide their goals for the visit and their medical history, and take notes during the visit; these data become part of their record.10, 11
  6. Effective communication–Eye contact is critical in virtual office visits. Look into the webcam and not at the screen or down at papers. It is important that the patient see your entire face by viewing the smaller camera on the screen. Lean in and nod as appropriate. Be mindful of your facial expressions and how they may be perceived. Ask questions that keep your patient engaged.8,9
  7. Define postappointment instructions–OurNotes or other similar programs are tools for the patient to use during the visit and to record critical information to aid in knowledge retention.11 Ensure your patient knows how to obtain their medications and make follow-up appointments. Include enough time to answer questions and clarify instructions.9

Patient education

Educating and training patients on using this new technology is essential for virtual encounters to be successful. Many factors, including patient age, healthcare status, computer skills, and willingness to try this type of visit, may influence the success of this process. Explain to the patient that you are now using telehealth for conducting this visit, but the same meaningful data will be obtained to make a diagnosis and set up a treatment plan, as with face-to-face visits. This may help assuage any patient concerns as to how meaningful a virtual office visit can be in providing appropriate and patient-focused healthcare.12

To this end, one needs to start by educating patients in the use of telehealth technologies and explaining the benefits of telemedicine as they relate to the individual and safe patient care in the pandemic. Identifying how the virtual visit will positively impact their health can personalize the concept for the patient. For the patient approaching telemedicine and telehealth for the first time, providing a brochure regarding how the telehealth program functions (that is, step-by-step instructions for the entire process) can start a conversation about and ease the fears surrounding the telehealth visit. The brochure should be written at a sixth grade reading level and include clear graphics illustrating the process for those who are illiterate. Depending on the patient population the NP serves, brochures written in various languages may be needed and the necessary materials mailed, emailed, or put in the patient's portal.13

When talking with the patient, standard expectations about the use of terms should be used as with any face-to-face visit (for example, avoid the use of medical jargon and talk about the visit as virtual instead of telehealth, because the latter term may be unfamiliar). Provide opportunities for questions and let them know that questions are appropriate at any time–before, during, or after visits. Consider having a demonstration with an office staff member, so the patients can see how a visit occurs and the technology works to ensure the visit goes smoothly and the NP can focus on the healthcare issues at hand rather than the technology.13

Finally, go over equipment the patient will need, including a webcam, mobile device, or computer as well as a microphone, if one is not part of their device. For some patients, how to use this equipment may be a stumbling block requiring more education or their equipment may not be current enough to work with video-conferencing programs. Patients with limited technology and/or internet connection should be provided alternative platforms for video-conferencing or nonvideo visits.13 If the patient has access to a patient portal but is not presently using it, the patient should be asked to register and informed that this is an optimal way to communicate with providers.12

Perceptions of telehealth

Both patients and providers are becoming more satisfied with and aware of the usefulness of telehealth during this pandemic. Like with any technology, glitches occur, but they can be managed. Issues with lack of broadband will continue until it becomes universal and consistent. Many more rural communities are working to provide all their citizens with free broadband access, but this takes time especially in the current pandemic. Consequently, for those with inadequate or nonexistent broadband, telehealth will have to depend on less “high tech” solutions impacting satisfaction.

Patient perceptions of telehealth

Patient perception of care received during a telehealth experience can be impacted by one's skills with technology; access to broadband; availability of a computer, smartphone, or tablet (that is, cost issue); and attitude toward virtual visits, such as lack of personal touch and privacy concerns, which can be especially impactful if the patient is an older person or has vision or hearing issues.14,15 Despite these possible challenges, prior to the pandemic, patients and healthcare providers reported high satisfaction with telehealth and its convenience and quality of care.14,16 Currently, patients' attitudes toward telehealth are being shaped by the pandemic, social media, social distancing, and heresay. However, attitudes do change and more patients are willing to have further visits after experiencing their first one, due to allayed concerns and a better understanding of how the technology works. A Sykes survey of 2,000 adults across the country found that two-thirds of the surveyed population believed the virus had increased their willingness to have a telehealth visit.17 One quarter did not know telemedicine and telehealth were options for care. However, 15% said that the pandemic would not increase their use of this technology– most of these individuals belonged to the 35-45-year-old group and lived in the South. Only a few knew of someone who had been screened for coronavirus disease 2019 (COVID-19) using telehealth, and these individuals were mostly in the 25-34 and 18-24-age groups.17

Provider perceptions of telehealth

It has been noted that healthcare provider perceptions related to using this communication technology prior to COVID-19 were as positive as they were for patients. They found clinical effectiveness to be similar to in-person visits and costs to be lower for them and their patients.4 As yet, no studies have reported how healthcare providers are perceiving telehealth during this pandemic. However, there are anecdotal articles that report issues that include those already mentioned, such as trouble using this technology. Overall, healthcare providers have been satisfied with the use of telehealth, and one example included a story by a physician who shared his enjoyment of seeing a patient in his pajamas as well as his dog, cats, and house.18

How to start using telemedicine technology

Many healthcare organizations still have limited telehealth services, but with the advent of the pandemic this is changing rapidly and in-person encounters are no longer the norm. Many large healthcare organizations experienced only a few telehealth visits a day prior to the pandemic compared with many thousands of telehealth visits each month now related to COVID-19. In spring of 2020 it was estimated that telehealth visits would increase to a billion visits by the end of the year nationwide, with 900 million of those visits related to COVID-19, and that the US telehealth market would reach around $10 billion in 2020.19

Many electronic health record (EHR) platforms already have basic telemedicine functions, but they are not robust enough for an optimal experience with the heavy caseloads being seen by many healthcare organizations. Some vendors have standalone platforms that are more robust, and include some of the following features: scheduling appointments, e-prescribing, sharing imaging and lab results between healthcare providers and patients, and managing upcoming patient visits. However, there may be an issue with a lack of integration with specific EHRs or portals and between differing healthcare systems, offices, and clinics, which will require another method to handle patient data and may necessitate the patient downloading another app.1

Video-conferencing tools, such as Skype, Zoom, and FaceTime are familiar to many and fortunately can be used for visits during the pandemic as a result of HIPAA compliance waivers regarding patient/provider data as they relate to the use of these technologies. This may be of concern when the waivers are lifted or a decision is made not to extend them. Some large organizations still do not allow providers to use these platforms unless they meet HIPAA compliance requirements. Google Hangout, Skype, and FaceTime do not offer HIPAA compliance as a safeguard to the data. Consequently, providers should look for vendors that do ensure this security. Regardless, the data need to be encrypted.1

Verifying patient identity will not be an issue, if the person is a current patient who uses a portal. New patients should be given a username and password to access the site. Internet speed has to be sufficient to manage the video-conferencing for both the provider and patient and providers need to be aware that peak load times can vary. Patients accessing telemedicine through their patient portal can utilize the “store and forward” interactions through messaging between them and their providers. Finally, remote monitoring data from measurement devices can be shared between healthcare providers and their patients in a more real-time setting.1

Telehealth resources

Resources are available to assist NPs as they implement or participate in using telehealth technologies (see Telehealth resources). A primary resource is the National Consortium of Telehealth Resource Centers.6 Local resources should be considered as well. Asking about the experience colleagues have had and tips they can share will provide real life examples that can be helpful.

Conclusion

The education and training of providers and patients in the use of telehealth and its accompanying technologies is an evolving process with both groups coming to this experience with varying skill levels, understanding and appreciating its use. Because of the pandemic, getting everyone up to speed is an issue. Patience by all stakeholders will be important as everyone seeks to figure out how this new encounter takes place. Telehealth and telemedicine processes are becoming more commonplace and useful and comfort levels will increase accordingly. It is the responsibility of NPs to assist patients as they learn how everyone functions in this new environment and how to use the technologies. Fortunately, there are many resources available for providers as they seek to learn and perfect this new way of having visits with their patients. Telehealth and telemedicine can reduce costs for organizations and lessen the need for personal protective equipment required during face-to-face visits. Lastly, this is a modality that can be used to enhance the healthcare system's ability to meet the healthcare needs of patients during COVID-19 and beyond and this is the goal of the NP in providing the healthcare their patients require and deserve in all settings. In the third article in the series, both patient and provider limitations of telehealth will be explored along with real life experiences of providers and patients: how negative visits can be improved, salvaged, or become points of teaching. The implementation of an actual telehealth visit will also be presented.

- Telehealth resources
1. National Consortium of Telehealth Resource Centers— www.telehealthresourcecenter.org/
2. US Federal government— https://telehealth.hhs.gov/
3. Telepsychiatry Toolkit— www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit
4. American Medical Association Digital Health Implementation Playbook— www.ama-assn.org/amaone/ama-digital-health-implementation-playbook
5. American Association of Nurse Practitioners COVID-19 Policy and Practice Updates— www.aanp.org/advocacy/advocacy-resource/coronavirus-disease-2019-covid-19-policy-updates
6. Health Informatics and Telehealth Specialty Interest Group— www.aanp.org/membership/aanp-communities/informatics-telehealth-sig
7. Alliance for Connected Care— http://connectwithcare.org/
8. American Telemedicine Association— www.americantelemed.org/
9. National Telehealth Technology Assessment Resource Center— https://telehealthtechnology.org/
10. State Medicaid & CHIP Telehealth Toolkit— www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf

Disclaimer: The content and information here was current at the time of writing and is subject to change.

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Keywords:

COVID-19; pandemic; telehealth; telemedicine

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