Telehealth Integration and OptimizationImprove Patient Care Through Virtual Health Care Delivery

This toolkit will aid the learner in identifying types of telehealth services, employing efficient telehealth workflows, and understanding the impact of key regulations.

Before the COVID-19 pandemic, an aging population, geographic and socio-demographic disparities in access to care, and health care professional workforce shortages drove the desire for virtual care. With the COVID-19 Public Health Emergency (PHE), telehealth services became critical to ensure access to care, reduce patient and health care provider exposure to disease, protect vulnerable populations, conserve personal protective equipment, and improve clinical outcomes. As a result, the PHE and related federal and state waivers, executive orders, and legislation exponentially accelerated the adoption of telehealth. While the PHE may eventually expire, many practices have now experienced the benefits of telehealth. A recent American Medical Association survey revealed that 70% of physicians stated that their organization would likely continue using telehealth in the future.¹ Patient satisfaction rates with telehealth services are also high, and physicians concur that the patient experience is enhanced by telehealth.^1,2 However, the nationwide adoption and growth of telehealth led many practices to revert to the “doctor does it all” model of practice—an approach that is neither sustainable nor effective. This toolkit and the related AMA STEPS Forward® toolkit on Telehealth and Team-Based Care describe STEPS to successfully integrate and optimize telehealth in your practice with team-based care models and workflows in mind.

What Is Telehealth?

Telehealth is a broad term encompassing a range of technologies and modalities that enable clinicians to provide health care services from a distance. Figure 1 provides some useful definitions.

1. Create a Strategic Plan

2. Decide Which Types of Telehealth Services to Offer

3. Choose the Best Telehealth Platform for Your Practice

4. Understand Relevant Telehealth Laws and Policies

5. Develop Team-Based Telehealth Workflows

6. Assess and Optimize

Strategic planning to integrate telehealth solutions is imperative in a small practice or a large hospital system. A successful telehealth program requires planning both clinical and non-clinical aspects of care delivery. Having a checklist handy can help you through the planning process. Stakeholders to involve in strategic planning include:

• Physicians

• Care team members (nurses, medical assistants, etc)

• Registration team members

• IT department

• Billing, legal, and compliance departments

• Risk management

• Marketing

Whereas large hospital systems may have individuals dedicated to each of these areas, smaller practices can be equally successful by ensuring that managers maintain focus on these critical aspects of telehealth operations. As with all transformations, the support of a high-level leader is crucial to success.

Determine as a practice what types of services you will offer via telehealth. Though many ambulatory settings implemented telehealth in 2020 to address the COVID-19 pandemic, its use is no longer limited to COVID-related circumstances. Practices can use telehealth for new and established ambulatory and inpatient encounters. Other telehealth services payable under the Medicare Physician Fee Schedule include*:

• Emergency department visits

• Observation visits

• Nursing facility visits

• Diabetes management visits

• Mental health counseling

• Advance care planning

• Psychological and neuropsychological testing

• Therapy visits (eg, PT and OT)

• End-stage renal disease (ESRD) monthly services

• Transitional care management (video required)

• Medicare Annual Wellness Visit (video required; note that the Welcome to Medicare Visit (G0402) is not on the list of approved Medicare telehealth services)

*Current as of August 2, 2022. Please note this list is subject to change along with the Public Health Emergency; refer to CMS for the most up-to-date fee schedules.

For primary care ambulatory visits, Table 1 gives examples of the types of visits to consider for telehealth vs in-person. This list is not comprehensive or definitive and should be adapted to your specific practice.

For specialties outside of primary care, many specialty societies have developed practice guidelines to identify appropriate telehealth cases, such as telehealth standards in oncology, telepsychiatry practice guidelines, telestroke guidelines, etc. You can find a list of specialty societies and linked telehealth guidelines on the Mid-Atlantic Telehealth Resource Center (MATRAC) website by clicking the “Specialty and Setting Specific Guidance Documents” tile.

Choosing or switching to a telehealth platform that suits your practice needs is essential. As you evaluate telehealth platforms or vendors, think about the following questions related to privacy and security, logistics, and patient support and usability.

Privacy and security questions:

• Will the vendor ensure compliance with HIPAA privacy and security requirements?

• How does the vendor protect personal health information (PHI)?

• What will the vendor do in the event of a security or data breach?

Logistical questions:

• Can the platform be embedded into your existing EHR, and what are potential obstacles to integration?

• Does the platform support mobile device access?

• Does the platform support remote examination tools?

• Is medication reconciliation integrated into the platform?

• Can patients consent to receive telehealth directly on the platform?

• Does the vendor support language interpretation?

• Can a caregiver, scribe, trainee, or others join the conversation?

• Does the vendor offer an enterprise solution, or is the service provided as a per-user license?

Patient support and usability questions:

• Do patients need to download an app for virtual visits?

• Must the patient access the platform via a patient portal, or can a link be shared directly with the patient?

• What are the minimum bandwidth requirements for patients? (eg, some telehealth platforms can support video conferencing as low as 600 Kbps)

• Will the platform enable the patient to test their audio and video before connecting with the clinician?

• Is there a waiting room feature?

• Does the platform permit direct scheduling by patients?

A recent American Medical Association survey (PDF) shows the various telehealth platforms that physicians are using (Figure 3).

The AMA Telehealth Implementation Playbook (PDF) has additional details about choosing a platform in Step 4: Evaluating the Vendor (page 32).

Any care delivery model your practice implements must conform to all federal and state laws and standards related to billing, privacy and security (including HIPAA), informed consent, medical licensure, credentialing and privileging, prescribing, quality reporting, and liability. The Health Resources & Services Administration (HRSA)-funded Center for Connected Health Policy offers resources to assist practitioners with state-specific and federal policies impacting telehealth practice. You may also find relevant Medicaid and Children's Health Insurance Program (CHIP) telehealth policies in a toolkit (PDF) and supplement (PDF) published by CMS.

Telehealth workflows should parallel existing in-person workflows as much as possible and utilize team-based care principles. Care team members should be actively involved in patient rooming, documentation, and follow up. Before the physician sees the patient for the virtual visit, care team members can:

* Ask patients for vitals

* Perform medication reconciliation

* Enter the chief complaint

* Add other elements of the History of Present Illness (HPI) and past history

* Set the agenda

* Troubleshoot any technical issues

The related AMA STEPS Forward® toolkit on Telehealth and Team-Based Care provides detailed workflows based on staffing levels and other practice resources available.

Physicians should determine how best to integrate telehealth into their schedules. For example, they can choose to schedule telehealth visits along with in-person visits throughout the day or set aside a block of time, or even a full day, for only telehealth visits. However you decide to integrate telehealth into your practice, set patient expectations accordingly. Just as with in-person visits, physicians may run late from their prior visit or, conversely, they may be ready to call a little bit earlier than scheduled.

The AMA Telehealth Implementation Playbook (PDF) has additional details and guidance on designing telehealth workflows and preparing patients and team members (pages 46-63).

As with any change in process, the following strategy will help you on the road to success:

• Start with a pilot

• Engage champions and early adopters

• Capitalize on and communicate successes internally

• Get frequent feedback on inefficiencies and opportunities for improvement

Track performance, clinical, and financial metrics The AMA Telehealth Implementation Playbook (PDF) has additional details and guidance on implementing, evaluating and scaling successes for telehealth integration (pages 64-75).

Telehealth is an actively evolving part of modern health care delivery that is here to stay. While many practices and organizations around the country had no choice but to hastily implement telehealth due to the COVID-19 pandemic, it is important to reassess and optimize telehealth models and workflows. By doing so, your practice can improve patient access, satisfaction, and continuity of care, while enhancing care team well-being and increasing revenue.