7 Steps to Implementing a Telehealth Program: COVID-19 Solutions
Author Carolyn Rutledge, PhD, FNP-BC
Co-Author Tina Gustin, DNP, CNS
Editor Elizabeth Moran, MSN, RN, CPNP-PC
With the challenges facing our nation as a result of the COVID-19 pandemic, providing safe, efficient, and effective healthcare has become a major priority. While Emergency Departments (EDs) and Intensive Care Units (ICUs) bear the brunt of COVID-19 cases, ambulatory care providers can no longer deliver care as they know it. Strategies to prevent the transmission of COVID-19 demand that telehealth programs be implemented. To do so, most healthcare delivery programs are turning to telehealth for routine and preventative care. Virtual appointments are a more appealing alternative in that they allow physical distance while still delivering care. As such, exposure risk is decreased for both patients and providers.
One of the greatest concerns facing providers and patients is a limited understanding of how to implement and utilize telehealth. This blog seeks to address the steps that should be taken. Specifically, we’ll walk you through steps to setting up a telehealth program, ascertain patient involvement, carry out an encounter, and provide follow-up.
Steps to Establishing a Telehealth Program
Starting a telehealth program requires a set of specific steps in order to make sure the program can be successfully implemented. The healthcare site must decide: 1) what patient population or healthcare issues will be addressed, 2) what services will and can be provided, 3) what technological equipment will be needed, and 4) who will be involved in the delivery of services (administrative staff, nursess, information technology, etc.
Although some healthcare programs quickly began implementing telephonic encounters, most have an ultimate goal to provide video conferencing sessions. In order to do so, proper equipment must be obtained, set up, and tested. It is imperative that the providers practice with the equipment prior to a visit in order to optimize the delivery and minimize complications. Those that will be providing the care should be aware of telehealth etiquette (how to effectively deliver telehealth). Old Dominion University has developed free videos for training in telehealth etiquette.1 Protocols should be put in place for encounter delivery and on how to handle emergency situations.
Contacting the patient varies by the telehealth services delivered. Some services require the patient to initiate the visit. If so, there should be a straightforward process in place to instruct patients in obtaining telehealth services. Providers will also need to determine technology available to patients (computers, smartphone, iPads, etc.) and the ability of the patient to participate in videoconferencing. You may choose to send patients a consent form to complete ahead of the visit or verbally attain consent at the start of the call. Information on how to participate in the telehealth encounter with step-by-step instructions, including how to make contact if the connection is broken during the visit, is essential to avoid patient frustration.
Immediately prior to the telehealth encounter, providers should obtain all data needed for the visit (medical records, lab and other test results, referral notes, etc.), as one typically would for in person visits. Providers should know if a consent is required and if so, whether it has already been obtained. Some states require a written consent whereas others accept a verbal consent. Test any technological equipment prior to the call to make sure it is working appropriately and well charged. Finally, note the time you begin the encounter as this is necessary information for billing purposes.
Beginning the visit requires an introduction of the participants, purpose, and process.
- Identify who is present at the patient’s site and their location as well as the patient’s location at the time of the call
- If this is a new patient encounter you may want them to show you a picture ID. This will assure patient identity.
- Identify who is present in the provider’s site. If the patient does not know you, you may want to show an ID, too.
- Clarify the purpose of the encounter.
- Establish agreement with the patient on the purpose.
- Obtain verbal approval/consent for the visit. Chart that verbal consent was obtained.
- Outline the procedure that will be used in the session.
- Inform the patient on how the security of information will be maintained.
- Collect information that might be needed in case of an emergency (their location/address and name/number of an emergency contact person).
- Inform the patient that he or she has the right to terminate the call at any point and go directly to the emergency department.
During the telehealth encounter, the provider will replicate the same standard of care and data gathering that would be used in an in-person visit. The provider will obtain the same history/subjective data from the patient via verbal communication. They may also need to collect physical data in many cases (i.e. if a patient’s chief complaint is a rash). The biggest difference in gathering this data will be the inability to touch the patient. Approaches to obtaining the physical data will need to be modified in order to complete the assessment. Thomas Jefferson University has developed a CME/CEU accredited module that helps prepare providers to collect physical data for the specific condition using telehealth.2
Conducting a Physical Exam via video conferencing
- Vital signs/labs – Have the patient provide you with VS and lab results using devices they have at home when possible. Examples of devices may include: smartwatches or Fitbits, blood pressure cuffs, thermometers, scales, glucometers, etc.).
- Skin conditions/lesions – Instruct the patient to place the impacted area close to the camera for viewing. Have the patient or a family member describe drainage, warmth, tenderness, changes in appearance, and/or texture as needed.
- EENT – Guide the patient to look at the camera on their computer/iPad and use a flashlight or the light on their Smartphone to shine in their own nose or mouth while tilting their head back. Have the patient open their eyes wide and pull their lids down as you check the eyes for redness or drainage. Have patients feel under their jaw for glands and describe if they feel sore or swollen.
- Cardiac – Have patients report their weight, press in areas of their lower extremities to assess for edema, measure their legs or abdomen to assess for fluid retention, and/or use a Smartwatch to show their EKG.
Ending the encounter should include a discussion of the assessment and plan, including follow-up and a plan for future visits, tests, and/or referrals. Verbally discuss the plan using teach-back techniques and then follow-up with a HIPAA secure email or text with written instructions, when possible. Providers should not use their personal phones for sending texts (patients will have your phone number). Text-based platforms that are HIPAA Compliant and SMS Based include Tiger Connect, Updox, and pMD. Just as you did at the start of the visit, also remember to document the time the encounter ended. As always, be sure to document the visit as well as the follow-up plan.
Video Conferencing Platforms
During this time of crisis, many HIPAA compliant platforms are rapidly becoming available for free or a low charge. Providers will need to select the option that fits best for them and their practice sites. In choosing a platform, the provider should determine whether a Business Associate Agreement (BAA) is needed. A BAA is a legal agreement between the healthcare organization and business associate that defines the use, handling, and protection of, and responsibility for patient health information (PHI). The list of platforms below are being provided as options for video conferencing. Please note, Melnic does not specifically endorse any of these services.
Potential Video Conferencing Platforms
Doxy.me (Free for limited services)
SimplePractice (Part of a wider practice management platform for small businesses in health and wellness. First 30 days free)
Zoom for Healthcare (you may want to see if you have zoom at your site)
VSee (Optimized for areas of poor internet service. Good for clients overseas or in rural areas) https://vsee.com/
Vidyo (good with low band width, being offered at no cost to address COVID-19 crisis https://info.vidyo.com/vidyo-license.html
Bluestream (being offered for free for COVID-19 crisis) https://www.bluestreamhealth.com/covid-19-general-guidance/
Adaptive Telehealth (Offer many services for low cost including scheduling and secure emails) https://www.adaptivetelehealth.com/index.php/provider
The information provided through this blog provides a framework to help providers continue to provide quality, effective care in our current environment and perhaps beyond. As many have come to express great appreciation for telehealth, we suspect the COVID-19 pandemic will have lasting effects on how healthcare is delivered in America forever. We understand that this is a trying time for healthcare professionals and reshaping the way we deliver medicine so rapidly is a stressful endeavor. Following the steps as outlined above can ensure both the provider and the patient have a satisfying and productive encounter. Flexibility is key. Barriers will be overcome. To stay abreast of changes and receive support for telehealth in specific regions of the country, 12 Telehealth Resources Centers may be accessed via their websites. Go to https://www.telehealthresourcecenter.org/ to find the Resource Center for your region.3
- Telehealth Etiquette. https://www.youtube.com/watch?v=YVJOesPIdc4&list=PLM0VF0yZsE6f6737BT0QdUp7iC9BMINyC&index=2
- Telemedicine: Conducting an Effective Physical Exam. https://cme.jefferson.edu/content/telemedicine-providers-conducting-effective-telehealth-physical-exam#group-tabs-node-course-default1
- The National Resource Center with links to the regional center. https://www.telehealthresourcecenter.org/
Or, are you hiring? If you want to discuss telehealth implementation with your peers, we can connect you. Let’s talk, Jill Gilliland, President, Melnic. firstname.lastname@example.org
is Professor and Associate Chair of the School of Nursing at Old Dominion University (ODU). Dr. Rutledge has published over 55 articles and served as an investigator on 28 successful grant applications totaling over $18 million with a primary focus on utilizing new models of care such as telehealth to provide care to rural and underserved populations. Since 2010, Dr. Rutledge has focused on improving the way healthcare is delivered in remote areas using telehealth to enhance patient care and communication. She was the lead in developing the NONPF position paper on educating Nurse Practitioners in telehealth. She is a sought-after national consultant in the area of telehealth education and has a book, “Telehealth Essentials for Advanced Practice Nursing” in press. She is currently serving as the Academic Director of the Center for Telehealth Innovation, Education, and Research (C-TIER) at ODU. In 2014, Dr. Rutledge received the SCHEV Outstanding Faculty Award, the highest honor provided to faculty in Virginia.