Provider to patient visits include 2 locations:
Patient location – Typically, patients will initiate and/or participate in a VE when and where they feel most comfortable and in a location they consider to be appropriate. While it can be assumed that they have selected their own "site," some general principals should be adhered to. All encounters should be done in a private environment to avoid sensitive patient information from being heard or seen by unauthorized people. While patient information should not be stored on a local device, equipment and devices should deploy the proper security measures such as encryption and user authentication in order to provide the highest protection for patient information left on the device. Patient should wear the same attire as they would have for an in-person visit. Patient should be ready to discuss and/or show their medications and medical equipment with the provider during the encounter. For both live and store-and-forward encounters, the location where information will be acquired should be well lit and quiet, while the information should be acquired and transmitted securely and directly onto the provider's secured server. For peripheral devices and devices that are worn, these devices should be adequately vetted by the provider site for accuracy, security and reliability. All electronic transmission of patient information should be secured, appropriately encrypted, and authenticated to the right user.
Provider site – All types of encounters should be done in a professional environment with complete privacy to avoid unintentional and inappropriate sharing of sensitive patient information. For live encounters, the location should be quiet, well lit, distraction-free, and have maximal bandwidth to ensure the best video and sound quality transmissions. Providers should dress professionally. All equipment and devices should deploy the proper security measures such as encryption and user authentication in order to provide the highest protection for theft of patient information left on the device.
The following people are integral to the VE:
Patient – The person who is receiving healthcare services in the virtual encounter. The request for services may not necessarily be the patient (e.g., in the case of younger pediatric patients). Federal, state, and/or local regulations may apply in the case of adolescent patients and/or regarding patient confidentiality.
Provider – A physician or non-physician provider (dentist, nurse, nurse practitioner, psychologist, physician's assistant, dietitian, pharmacist, physical therapist, etc.) that provides healthcare to the patient via telemedicine with similar standards to an in-person patient visit. It is imperative that the provider have role in a patient's medical home and be familiar with patient history; access to health records; ability to refer to in-person care.
Referring provider – A physician or non-physician provider who is referring the patient for the VE. Often this is the primary care physician, but can be another subspecialist. This person can be the tele-presenter, if needed.
Primary care physician – The physician provider for the patient's medical home. In order to avoid the fragmentation of care, the primary care physician should be promptly updated on the discussion and plan of care derived from all virtual encounters between the patient and any other provider. This should occur within the patient's medical record.
Who is the technical engineer? This person is responsible for ensuring that the technology is functioning properly, updated with the latest compatible software, and tested periodically to ensure highest performance. The technical engineer should be ready to assist and troubleshoot if unexpected problems occur, including during live sessions.
Relation with the telehealth program – Direct to consumer (DTC) encounters are increasing as the consumer (patient) is increasingly demanding convenient and timely services. These direct to consumer or virtual encounters are an important pillar of a telehealth program.
Operation and site coordination – The telehealth coordinator evaluates partner sites and their clinical needs and requirements. In the case of DTC or VE, the operation and site coordination should identify, assist and expedite patients' access to care with a focus on reducing patient and provider costs (in time, dollars, and resource allocation).
Clinical direction and oversight – Oversight of DTC services or VE should ensure that the clinical services are provided appropriately, meet the needs of the patient, and are accessible. A streamlined workflow for initiating and conducting the encounter should be clearly illustrated and communicated to the clinicians of the referring patient (if at provider office) as directly to the patients (if at home). Informed consent, in some cases, may be required depending on state and facility regulations.
Technical support – Just in time technical support is critical to help participants (especially first time patients or providers) use the technology successfully and effectively. For example, coaching on camera position, lighting, and audio settings to adjust to the environment should be established prior to conducting a consultation. In addition, unexpected technological problems may arise that require an expert technician in real time in order to facilitate the visit. The technician can also track issues that were problematic and how they were resolved.
Technology: Virtual encounters can be accomplished by three modes of telemedicine technologies: live consults, store-and-forward services, and mHealth. These technology can be "off-the-shelve" systems, customized "off-the-shelve" technologies. The desired functionalities will typically drive the technological options and deployment strategy. A public location such as a pharmacy store may require the use of a self-contained private 'telemedicine booth,' whereas a physician or school office can use a telemedicine or computer cart that is brought into the patient's examination room. For some patients, a mobile solution on smart phones and tablets may be the only practical option, in which case, adherence to best practice guidelines (i.e. no distracts, no public sessions) would be critical. Use of remote monitoring devices such as glucose monitors and activities trackers will require a robust system for monitoring by qualified healthcare providers and safe response and management protocols. The desire to have synchronous or asynchronous telemedicine encounters is also critical and dependent on the circumstances of the patient and location (see table below).
|Patient at home||PMD or subspecialist visits; home care monitoring of ventilators, mostly existing patients or doing a follow-up||Diabetes management, telemetry, photos (otoscope, wound care or other dermatologic issues, etc.)||Activities and caloric intake tracking for wellness management|
|Patient at school||School nursing office, attending class from home||Images of eye or middle ear|| |
|Patient at provider office||MD-MD consultation with patient in the room||Photos, subspecialty consultations|| |
Quality and safety concerns include:
- Are services conforming to the current standard of care for these diagnoses (e.g., UTI and otitis media)?
- Do providers have an established patient relationship?
- Are the plans of care resulting from virtual visits as safe, effective, efficient, and cost-effective as in-person visits (providers able to prescribe prescriptions, make referrals, recommendations)?
- Is patient compliance different than in-person visits?
- How does the telemedicine encounter improve care in terms of the Institute of Medicine's Quality Dimensions (Efficiency, effectiveness, equitable, timeliness, safe, and patient centeredness)?
Appendix A: Template 'Swimlane' Workflows
- Provider – patient (after hours)
- Provider - patient (during office hours)
- School- based telemedicine