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COVID-19 and telehealth

How to complete a successful telehealth visit

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

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doi: 10.1097/01.NPR.0000751808.74986.82
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In this series of articles, we explore how NPs can help their patients adapt to the new and changing healthcare environment and modes of patient care brought on by the pandemic, as many clinics reduce or eliminate in-person visits. The first article covered the history of telehealth, its benefits and challenges, as well as regulations, reimbursement, and licensure. The second article covered the education necessary for the NP, staff, and patient in using new technologies and appropriate behaviors to ensure a meaningful telehealth visit, in addition to perceptions from each stakeholder's points of view. In this last article, we will look at a telehealth visit based on several experiences the authors have had as NPs, family members, and patients.

Patient Mrs. P encountered issues while trying to connect with her NP, Ms. Mason, via telehealth. The most glaring problem was Ms. Mason's lateness to the appointment, and the lack of clarity as to the patient's recourse in such a situation. The dynamics of the encounter, as well as the patient's demographics, contributed to the start of a tense telehealth encounter. In the following sections, the dynamics of her telehealth encounter will be explored using the Four Habits Model.

The Four Habits Model includes groups of skills related to patient outcomes and categorized into habits that help one organize and act during an encounter. These habits are interrelated and provide a map for conducting patient encounters from asking and setting patient priorities, acknowledging the patient's viewpoint, and being empathetic in establishing a productive encounter with joint decision-making and required education.1

Mrs. P and her telehealth visit

Mrs. P is an older adult with congestive heart failure (CHF) who lives in rural Pennsylvania with internet via a phone line. Fortunately, she is able to have her BP and cardiac rhythm monitored remotely. Mrs. P's children have tried to help her learn to use these new technologies, but without success. Her children registered her for the healthcare organization's patient portal, but she is unable to access it unless her children are physically present with her. This is a concern while trying to social distance during the pandemic.

In order to minimize exposure to those outside the household, video-conferencing is the safest and the preferred method for healthcare visits with Mrs. P. The question then is how the NP caring for Mrs. P can move forward and help her and her family achieve a positive encounter virtually with good outcomes. With this in mind, one of her children who has avoided unnecessary exposure has been chosen to help their mother with the technology necessary for the virtual visit.

Mrs. P's NP: Patricia Mason

Mrs. P's provider is an NP, Ms. Mason, who, like Mrs. P, is new to this way of conducting business. She has been an NP for several years, so she is very comfortable with her clinical skills, but is concerned about the transition to virtual visits. Because she already has an established relationship with Mrs. P, she has a foundation for having a meaningful and effective telehealth visit. Mrs. P is obviously not comfortable with using this technology and is anxious how this new environment will affect the encounter and her relationship with Ms. Mason. These issues may impact how one or the other or both hear and understand what the other says. The use of the Four Habits Model will help bridge both their concerns and lead to a successful virtual visit.

Four Habits Model

The Four Habits Model was developed by Frankel and Stein in 1999 from previous work on medical interviewing effectiveness and their clinical work. While an old model, it is applicable in today's environment. Some of the supporting studies are older, but they are also appropriate to today's pandemic and expanding telehealth visits.

The model's four habits include: invest in the beginning, elicit the patient's perspective, demonstrate empathy, and invest in the end. The goals for this approach to interviewing include: “establish rapport and build trust rapidly, facilitate the effective exchange of information, demonstrate caring and concern, and increase the likelihood of adherence and positive health outcomes.”1 It is a model that fits very well with the virtual visit.

Having an open exchange and partnership between the participants during the visit influences the accuracy of a diagnosis, establishes trust in the process for the patient, and increases the patient's willingness to follow recommendations.1

Habit one: Invest in the beginning

The first habit, invest in the beginning, addresses three tasks: rapidly establishing rapport, fully exploring the patient's concerns, and designing the visit. The first few minutes of an encounter are critical to putting the patient at ease and establishing a trusting relationship. In in-person encounters, nonverbal cues are more easily picked up by both parties, but this is more difficult in a virtual visit. Consequently, it is important for providers to be aware of cues they may be displaying, such as eye contact (looking into the webcam), tone of voice, and facial expression. Since a handshake is not possible, a warm hello conveys one's pleasure in seeing the patient. This first step helps make patients feel welcomed, enables them to express their feelings/concerns, and establishes a trusting relationship, one in which they are both listened to and heard.1

Rapidly establishing rapport. For the encounter in question, Ms. Mason, following telemedicine etiquette and best practices, conducts the visit in her office which is quiet and private. Fortunately, since Mrs. P is well known to her, it does not take her long to review her electronic health record, including the remote BP and cardiac rhythm data. Ms. Mason is concerned about eye contact and nonverbal cues, indicating that she cares and is actively listening. Prior to seeing patients, Ms. Mason practiced conducting virtual visits with her family and friends to obtain feedback and get more comfortable with the technology.2

Mrs. P's daughter is present for the visit and has been able to successfully connect for the visit. They sign in 15 minutes prior to the appointment time as instructed; however, at 5 minutes past the scheduled time, Ms. Mason has not yet made an appearance. As with any provider, there can be circumstances that result in being behind schedule. It has been found that when a provider is late, patients prefer that they apologize, admit their fault, and offer an explanation for the delay.3 Ms. Mason knows that it is important to address any lateness as soon as she enters the telehealth visit. This will reassure Mrs. P that this visit is important, and that she is a valued patient. Once everyone is present, Ms. Mason apologizes for being late and explains that there was an emergent patient issue that required her attention, and then goes on to explain to Mrs. P that, just like their in-person encounters, she will be adding information into the computer during the visit.1

Fully exploring patient concerns. This is a scheduled appointment, so Ms. Mason does not anticipate new significant issues as none have been communicated. However, she is also aware that Mrs. P does not offer up concerns easily. Ms. Mason uses open-ended questions to enquire about any problems or concerns Mrs. P is having. Since Mrs. P is slow to respond, Ms. Mason gives her time to gather her thoughts to ensure there is time for her to answer and even enquires the daughter of any known problems. Often patients will not offer their real concern until after other problems are discussed.1

Designing the visit. When the visit starts, Mrs. P expresses worry about her activity level diminishing. Ms. Mason takes note, thanks her for sharing, and tells Mrs. P that they will explore this later in the visit. Ms. Mason then outlines what she expects to cover during this visit, making the visit more efficient.1 She goes on to tell her that they will review her current symptoms, diet, exercise, weight changes, and any other CHF concerns. They will discuss as much as they can during this visit, and then if more time is needed, they will plan next steps. At this point, Ms. Mason asks “How does that sound?” Mrs. P replies that it is fine. After discussing questions about how the pandemic may have changed Mrs. P's eating habits, exercise routine, and sleep patterns, they complete her current review of systems. Prior to moving on to their plan, Ms. Mason asks if there is “something else” Mrs. P wants to address in this visit. Asking if there is “something else” as opposed to “anything else” elicits a greater response by patients.4 In this case, Mrs. P again states her concern about functionality. Mrs. P currently has no signs of decreased ability to function, so Ms. Mason spends a few minutes delving into this topic aware that overall activities may be decreased during the pandemic.

Habit two: Elicit patient's perspective

The skills used in this step help the clinician formulate a more accurate diagnosis, more fully understand the patient's concerns or worries, and also demonstrate one's respect for the patient's culture and experience.1 This step includes three aspects: assessing patient attribution, identifying requests for care, and exploring the impact of symptoms on the patient's well-being.1

Assessing patient attribution. This aspect involves determining how patients perceive their symptoms or illness. Mrs. P has had CHF for a number of years, but still worries about how that impacts her life and her ability to function. To elicit Mrs. P's concerns about her health, Ms. Mason asks direct questions. Providers should ask direct questions to ensure that they hear patient concerns.1 Consequently, Ms. Mason uses the phrase “Can you tell me what your thoughts are about having heart failure?” Mrs. P replies, “I don't seem to have enough energy to do my usual activities.” Ms. Mason then explores for a few minutes what Mrs. P means by her response. As part of this discussion, Ms. Mason elicits any additional information her patient and family may have found through internet searches about CHF. She is interested to know if the information they found impacts how Mrs. P views her CHF. Mrs. P's daughter also adds that she has read that physical therapy may be helpful.

By understanding what meaning a patient gives to his/her illness, follow-up questions can be facilitated. Mrs. P goes on to explain that her husband had CHF and his ability to get around became very limited, and so she worries that the same may happen to her. It has been found that providers who elicit their patients' concerns receive higher satisfaction scores from their patients.5

Identifying patient requests. Patient requests or what they expect from a visit involves services or actions the provider initiates. This may include such things as medications or referrals. To elicit these expectations, it is important to ask directly what the patient wants accomplished from the visit. It has been found that when patients' expectations for a visit are acknowledged, patients are more satisfied with their visit.6 Mrs. P was hopeful that Ms. Mason might be able to help with her concern about remaining functional at the level she wants. Ms. Mason addresses this concern during the visit plus makes a referral to physical therapy, which may occur at her home or at the physical therapy agency.

Exploring the impact. The last aspect of this step is to determine the impact of the symptoms or illness on the patient. This can help strengthen the patient-provider relationship, offer evidence of the NP's empathy for the patient, and provide important information regarding the patient's mental and physical functioning. When Mrs. P expressed her fears about CHF and functionality, Ms. Mason replied, “No wonder you are scared.” In this way, the NP elicits a patient's perspective and demonstrates empathy, gathers important clinical data, individualizes care, and displays compassion.1

Habit three: Demonstrate empathy

Patients seeking medical care may experience many feelings, such as vulnerability, fear, anxiety, and anger. When providers acknowledge these feelings, patients feel like they are heard.1 With the COVID-19 pandemic, patients may have many more fears that can greatly impact how they are managing their mental and physical health. If clinicians miss the cues or words spoken by a patient regarding their fears or worries, then patients feel they are not listened to and that the provider does not care.1 Especially in the virtual environment, it is critical that NPs listen carefully and also catch the nonverbal cues of their patients. Ms. Mason observes Mrs. P's facial expressions, tone of voice, and posture as she responds during their interaction. These nonverbal cues provide more information regarding how Mrs. P is feeling and coping.

Expressing one's empathy to a patient requires three conditions: responding to emotions, recognizing opportunities to be empathetic, and projecting empathy through both verbal and nonverbal communication.1 When providers express empathy, it can reduce stress or anxiety much more effectively than providing reassurance.7 Ms. Mason cannot reach out and touch Mrs. P physically, but she can say such things as: “I understand how hard this is for you. What you're saying makes so much sense to me.”

Discerning empathetic opportunities. An NP may feel rushed or forced to capture important points during the visit and may miss the opportunity to express empathy. However, the additional time is minimal as compared with not responding and then having the patient repeat their fears over and over again, creating a very dissatisfying visit.7

Expressing empathy. An NP's nonverbal cues are important during any visit, virtual or in-person. There are ways the provider can show that they understand and have heard what the patient has conveyed verbally or nonverbally. These include: demonstrating encouragement by saying such things as “I am glad you told me about your fear of losing function” and “Tell me more”; identifying the concern through statements such as “It sounds like you are worried about maintaining your independence”; and, lastly, legitimizing patient concerns with statements such as “If I was in your position, I believe I would feel much the same.” There is evidence that demonstrating empathy can reduce unnecessary encounters, identify diagnoses that may have been missed, and establish greater trust and commitment to medical regimens.7

Habit four: Invest in the end

This last step involves sharing information. It is an opportunity for the clinician to explain what the identified findings/assessments were and to work with patient and family to make decisions about care.1

Delivering diagnostic information. It is important to use the same language the patient presents at the beginning of the visit. Mrs. P is concerned about her activity level and being able to take care of herself. Connecting the patient's words with what the clinician says improves the likelihood of the patient following the provider's recommendations.1 Ms. Mason states that she understands her worry and would like to refer her to physical therapy for evaluation to see what the next steps should be.

Providing education and joint decision-making. It is often times overwhelming for a patient to “hear” and understand what the clinician presents. Therefore, written information is critical to send home with the patient. The clinician needs to review the written material with the patient and ask if the patient understands the information. Since this is a virtual visit, reviewing the written material is a limitation. Mrs. P. will not have the material to follow along with Ms. Mason as she explains her recommendations. Ms. Mason then asks if these recommendations are in line with what Mrs. P believes, and allows time for questions about anything related to the material. Ms. Mason informs the patient that the handout will be emailed to her and available through the patient portal.

Research has shown that joint decision-making produces more satisfied patients and better outcomes.8 Mrs. P and Ms. Mason have discussed her concerns and strategies that will be of benefit to her ability to function at the level she wants. Part of education is assessing the patient's readiness to learn or make changes. Mrs. P is eager to try physical therapy to see how that might help her maintain or even improve her ability to do the things she wants to do.

Barriers to change need to be discussed when the patient is not ready for a suggested change. If not satisfactorily discussed, the patient may not follow plans decided together by the patient and NP.1 If the patient is not ready to make a change, the provider can suggest they leave this to a future discussion.1

Closing the visit. Ms. Mason ends the encounter by asking if the patient has any more questions: “What questions might you have about what we have discussed and decided upon?” Then after reviewing the next steps, she ends the visit with personal words, such as: “Glad we were able to have such a successful visit, and I look forward to our next visit after you are seen by physical therapy.”


This concludes the three-part series on telehealth visit. The first explored the history of telehealth; telehealth terms; its benefits and challenges; and regulations, reimbursements, and licensure. The second article examined education of staff and patients, their perceptions of telehealth, how to set up a visit, and resources that NPs can use to facilitate a virtual visit. In this last article, a virtual visit with an NP is explored using the Four Habits Model to guide the visit. The key to these virtual visits and their success is not losing the personal touch which the NP brings to in-person visits. Having a focus, directly addressing the patient's needs, and using nonverbal cues are vital for telehealth success, perhaps more than ever in this pandemic with the added worries and decreased access to in-person visits.


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8. Bot AGJ, Bossen JKJ, Herndon JH, Ruchelsman DE, Ring D, Vranceanu A-M. Informed shared decision-making and patient satisfaction. Psychosomatics. 2014;55(6):586–594. doi:10.1016/j.psym.2013.12.013.

communication, COVID-19; Four Habits Model; telehealth visit

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