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Top 7 Tips for Telehealth During COVID-19

David L. Feldman, MD, MBA, FACS, Chief Medical Officer

Though telehealth was an established method of delivering care before the COVID-19 pandemic, it has come into focus as physicians face an immediate need to reduce exposure by providing care—or at least triage—remotely when appropriate.

Under usual circumstances, telemedicine is comparatively low risk. That said, telemedicine does bring certain specific risks to both patient safety and physician/practice liability. Minimizing those risks calls for adapting daily practice routines around informed consent, documentation, and other standard components of a patient encounter, as well as adjusting the practice’s insurance coverage.

The following are seven recommendations for any medical practice starting to provide care via telemedicine:

  1. Distinguish between new and established patients.
  2. The foundation of care remains the physician-patient relationship. If someone you were seeing before this pandemic calls with a problem, it’s reasonable to either speak to them on the phone or have some kind of video chat.
  3. With new patients, however, proceed with caution. Likely your state or your insurance carrier usually requires that your first visit with a patient be in-person. During this pandemic, such restrictions may be relaxed—but just because you can treat a new patient by telehealth, doesn’t mean you should. A new patient may be more difficult to assess by remote means, and new patients are also more likely to be experiencing an acute situation that is not appropriate to treat by telehealth.
  1. Maintain privacy.
  2. Consider who is in the physical space or within listening distance of the patient-physician conversation when treating patients by phone or video chat. This includes other people in their space—and also yours.
  3. Physician-patient conversations are confidential. It’s up to the patient to determine who might be with them in their home environment during that visit, but it’s the physician’s responsibility to discuss the question of confidentiality. Also, you want the patient to know who from your staff is participating—unlike with an office visit, they may not know who’s in the room.  
  1. Prepare the patient before the appointment.
  2. Talk to your patient about whether it is in their best interests to pursue care by remote or virtual visit. This obviously depends upon your specialty, the patient’s presenting concerns, etc. When using this modality, as with any other, let patients know that they have a right to stop or refuse treatment.
  3. Consider not only your technology, but what patients are using. Have your staff review technology needs with patients before you begin.
  4. Receive informed consent from the patient to treat them by telehealth. This conversation doesn’t take long. A telehealth-specific informed consent form may already exist within your EHR system. As an alternative, The Doctors Company has created a sample informed consent that you can adapt to your practice. But at minimum, get your patient’s verbal consent to consult by telehealth—and document that approval in the patient’s record—before forging ahead.  
  5. Agree with your patient what you’ll do if there’s a technology malfunction, whether it’s to resume by phone or have the patient come to the office in person.
  6. You also want to talk to the patient about what telehealth means for billing. You may tell them, here’s what your insurance company says about it—or, we don’t know what your insurance company is going to say about it. States and insurers are making a variety of exceptions to their usual rules during COVID-19—but the exceptions keep changing, so billing is a moving target.
  7. First and foremost, do what you think is in your patient’s best interest as guided by good clinical judgment. Physicians need to be able to support their practices, but the payment has to come secondary to doing the best for your patient in the environment we’re in. We’re in a tough, confusing situation, but I believe that physicians are going to do the right thing, and that’s really what counts.
  8. The Centers for Medicare and Medicaid Services are periodically posting payment updates. Also check the webpage for your state’s health authority for updates regarding state-to-state licensing issues.
  1. Develop your web-side manner.
  2. Consider your surroundings as you prepare for video visits. You may realize that the brightly colored and patterned wall-hanging behind you could be distracting, and choose a plainer background.  If you are video-consulting with patients from a guest room in your home that has been hastily converted into an office, imagine the visit from the patient’s point of view: You’ll quickly think to turn the camera so that the background is your desk, not the guest bed, for a more professional tone.
  3. With newer patients, consider donning your white coat, if you weren’t wearing it already—and make sure your badge is visible. Clothing does look different on camera than it does in person, so when possible, choose solid colors over multicolored patterns, which can create a rainbow effect. Good colors for video include earth tones, deep blues, purples, and teal green.
  4. A little common sense will go a long way in removing distractions and maintaining a professional tone during telehealth visits.
  1. Call on creativity to “examine” patients remotely.
  2. It is true that some symptoms and conditions simply must be evaluated in person, and are not appropriate for care by telehealth. However, a virtual exam may be more informative than you’d think. For instance, one can assess for peritonitis by asking the patient to jump up and down. Musculoskeletal injuries may be assessed using the Ottawa knee and ankle rules. The Roth Score allows a preliminary assessment for shortness of breath and by simply asking the patient to take a deep breath and count out loud to 30—potential COVID-19 patients may be unable to get past seven. For more information about remote evaluation tools, start with the April 2020 article in NEJM Catalyst, “The Transition from Reimagining to Recreating Health Care Is Now.”
  1. Consider additional insurance needs.
  2. The COVID-19 crisis takes cybersecurity and cyber insurance needs to another level, because remote conversations with patients mean heightened risk for cybercrime. Consider seeking increased cybersecurity coverage during this time.
  3. This is also a good opportunity to review your business associate agreements with technology providers to understand who will be liable in case of a breach. Privacy liability is critical.
  4. Business interruption insurance also comes into focus now, because if you’re primarily delivering care via telehealth, any interruption in your communication technology can be considered business interruption. Consider adding or increasing your coverage in this area.
  1. Acknowledge when telehealth is not appropriate.
  2. A physician using best judgment can say to a patient, it’s hard for me to fully evaluate your symptoms using this kind of encounter, and I need you to come in. It’s easier to miss things with telehealth, so when you have that second sense you’re missing something—act on it.
  3. Of the telehealth-related claims we’ve seen at The Doctors Company, nearly 70 percent have alleged diagnostic errors, and most of those involved cancer. The risk of missing a cancer diagnosis by telehealth depends in part on what kind of physician you are. 
  4. Remember that a virtual visit is the next best thing—but not the best thing. If you in your best judgment think a physical exam is called for, and you think the risk of them coming to your office is less than the risk of not seeing them, then you should have them come to your office.
  5. For questions regarding HIPAA compliance with telehealth, and treating patients across state lines, please see our Telehealth Resource Center.


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

04/20

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