Emerging Practices in Telehealth: Best Practices in a Rapidly Changing Field 0443159807, 9780443159800

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Emerging Practices in Telehealth Best Practices in a Rapidly Changing Field Edited by Andrew M. Freeman, MD, FACC Director, Clinical Cardiology and Director, Cardiovascular Prevention & Wellness, National Jewish Health, Denver, CO, United States

Ami B. Bhatt, MD, FACC Chief Innovation Officer, American College of Cardiology, Associate Professor of Medicine, Harvard Medical School, Boston, MS, United States

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright Ó 2023 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-0-443-15980-0 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Mara E Conner Acquisitions Editor: Sonnini R Yura Editorial Project Manager: Sam Young Production Project Manager: Omer Mukthar Cover Designer: Mark Rogers Typeset by TNQ Technologies

Foreword For many of us, practicing medicine virtually was nothing more than a hightech dream of the future. Perhaps in training we talked of a future time when we could get vital signs and other data remotely and intervene in a patient’s health to improve outcomes. Fast forward to 2020. A highly contagious virus creates a pandemic with lockdowns in most of the world. All of a sudden, the dream of telehealth became a reality in every corner of the planet. Using adaptations of widely used videoconferencing software and techniques combined with newly created sensor and remote monitoring tools, most of the medical world was thrust into this vast new digital frontier. What emerged was nothing short of exhilarating. Incredible convenience, fast clinician access, and the avoidance of the drive, traffic parking, and wait time became common. People could access their favorite doctors from the convenience of their phonesdfrom home, work, or even while on a walk. Memories of the long gone “home visit” came rushing back for many of us as we gained insights into our patients’ homes and homelives. We, in some ways, felt more connected even though we were often miles apart. The world felt like a much smaller place through the magic of technology and widespread internet connectivitydeven in the poorest places on earth. Colleagues could connect virtually and provide consultations while patients in neighboring states were able to get specialty care they were unable to get locally or in a timely fashion. The good news is that telehealth is here to stay. Through widespread adoption coupled with incredible convenience, virtually all clinics and hospitals continue to support this vital tool which will only become more commonplace as technology and faster wireless access continues to develop. With sensors, batteries, and remote monitoring, listening, and measuring tools improving every day, perhaps the in-person visit will become the rarity. Only time will tell! As such, this book will serve as your trusty field guide for understanding how best to implement telehealth and will guide you through the technology, billing, legal considerations, global implementations, and the future of wearables. We hope you will keep this near your desk and use it as a practical implementation toolkit and a handy reference. We wish you the best success in your telehealth endeavors! - Drs. Andrew M. Freeman and Ami B. Bhatt xv

Contributors Nivee Amin, MD, MHS, FACC, Weill Cornell Medical College, New York, NY, United States Efstathia Andrikopoulou, MD, MBA, FACC, Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States; Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, United States Ami B. Bhatt, MD, FACC, American College of Cardiology, Harvard Medical School, Boston, MA, United States Jessa Boubker, JD, MPH, Health Care Practice Group, Foley & Lardner LLP, Boston, MA, United States Lindsay Brooker, MPP, Connected Care, UCLA Health, Los Angeles, CA, United States David Cho, MD, MBA, Department of Medicine, Division of Cardiology, UCLA Health, Los Angeles, CA, United States Ilaaf Darrat, MD, MBA, Pediatric & General Otolaryngology & Neurotology, Department of Otolaryngology Head & Neck Surgery, Henry Ford Health, Detroit, MI, United States; Revenue Cycle, Henry Ford Health, Detroit, MI, United States; Otolaryngology Clinic, Henry Ford Medical Center e Fairlane, Dearborn, MI, United States; Department of Otolaryngology, Wayne State University College of Medicine, Detroit, MI, United States Kseniia Eruslanova, MD, PhD, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University, Moscow, Russia Kyle Y. Faget, JD, Health Care Practice Group, Foley & Lardner LLP, Boston, MA, United States Andrew M. Freeman, MD, FACC, Division of Cardiology, Department of Medicine, National Jewish Health, Denver, CO, United States Jana M. Goldberg, MD, FACC, Heartbeat Health, New York, NY, United States; Columbia University, New York, NY, United States Mark A. Hanson, PhD, Heartbeat Health, New York, NY, United States; Department of Emergency Medicine, Innovative Practice and TeleHealth, The George Washington University, Washington, DC, United States Heather Hitson, MS, Connected Care, UCLA Health, Los Angeles, CA, United States Julia Kotovskaya, MD, PhD, Prof, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University, Moscow, Russia

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xiv Contributors Joseph C. Kvedar, MD, Harvard Medical School, Boston, MA, United States; Mass General Brigham, Boston, MA, United States Jayson S. Marwaha, MD, MSc, Beth Israel Deaconess Medical Center, Boston, MA, United States; Harvard Medical School, Boston, MA, United States Noor Osman, MPH, Heartbeat Health, New York, NY, United States Tracy Paul, MD, FACC, Weill Cornell Medical College, New York, NY, United States Venktesh R. Ramnath, MD, Clinical Associate Professor, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA, United States; Medical Director, Critical Care and Telemedicine Outreach, UC San Diego Health, La Jolla, CA, United States Priyansh Shah, MBBS, The World Youth Heart Federation, Vadodara, Gujarat, India Steven Shook, MD, MBA, Lead for Virtual Health, Clinical Transformation, Cleveland Clinic Staff Neurologist, Neuromuscular Center, Neurological Institute, Cleveland Clinic Clinical Assistant Professor of Neurology, CC Lerner COM of Case Western Reserve University, Cleveland, OH, United States Teresa Sieck, MPAS, PA-C, PhD, CEO and Presient, WebCareHealth, Ankeny, IA, United States Stacey Singer, MBA, CPMA, CCS, CASCC, CRC, CGSC, Revenue Cycle Management/Health Information Management, Cleveland Clinic, Cleveland, OH, United States Navjot Sobti, MD, Weill Cornell Medical College, New York, NY, United States Diala Steitieh, MD, Weill Cornell Medical College, New York, NY, United States Olga Tkacheva, MD, PhD, Prof, Russian Clinical and Research Center of Gerontology, Pirogov Russian National Research Medical University, Moscow, Russia Krista Vadaketh, MD, Weill Cornell Medical College, New York, NY, United States Aradhana Verma, MD, MTM, Department of Medicine, UCLA Health, Los Angeles, CA, United States Heba Wassif, MD, MPH, FACC, Director, Inpatient Clinical Section Services Medical Director, Cardio-Rheumatology Cleveland Clinic’s Heart, Vascular & Thoracic Institute Assistant Professor of Medicine Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve School of Medicine Cleveland, OH, United States Jeffrey D. Wessler, MD MPhil FACC, Heartbeat Health, New York, NY, United States; Northwell Health, Manhasset, NY, United States Aniket Zinzuwadia, AB, Harvard Medical School, Boston, MA, United States; Heartbeat Health, New York, NY, United States

Chapter 1

The basics of telehealth Andrew M. Freeman1 and Ami B. Bhatt2 1 Division of Cardiology, Department of Medicine, National Jewish Health, Denver, CO, United States; 2American College of Cardiology, Harvard Medical School, Boston, MA, United States

Introduction Telehealth, as defined by the U.S. Department of Health and Human Services is defined as: Telehealth d sometimes called telemedicine d lets your doctor provide care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone.1

For practitioners, however, telehealth is more than just a way to provide healthcare services. Telehealth allows for removal of barriers, quick and convenient check-ins, insights into the ways patients live, and allows for more personal time spent with the patient than what has often become a hurried office visits with shuttling between check ins, check outs, billing and payment, and other services. The coronavirus pandemic may have hastened the rapid uptake of telehealth services, but for those of us who have long thought that the everyday workings of modern medicine were too time-consuming, inefficient, and impersonal, the rapid adoption and availability of telehealth was overdue. In the next chapters of our book, our group of well-known authors in the telehealth space will guide you through the many aspects of doing telehealth well, the best ways to bill, the best ways to operate, and the best ways to connect with your patient. You’ll see pearls, caveats, and the future of telehealth and how in combination with remote monitoring, sensors, and wearables, the entire ecosystem of modern medicine will shift.

Statistics According to the Centers for Disease Control and Prevention (CDC), telehealth utilization grew rapidly by more than 154% in late March of 2020 compared to the same period in 2019.2 It is expected that expenditures will exceed $397 billion USD on telehealth services by 2027 per the predictions made by Fortune Business Emerging Practices in Telehealth. https://doi.org/10.1016/B978-0-443-15980-0.00014-4 Copyright © 2023 Elsevier Inc. All rights reserved.

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2 Emerging Practices in Telehealth

Insight.3 Further, to put this all in perspective, in 2019 the market was only worth $42 billion USD, and with the pandemic, the growth is on a steep rise.3 As of July 2021, telehealth utilization has stabilized at 38 times higher than prepandemic levels. Interestingly, it was at an all-time high in April 2020, just shortly after the pandemic began with a record of nearly 80 times higher than prepandemic levels.4 The AMA commissioned a survey, even prepandemic, which supported the increased use of telehealth. In that survey they found that 68% of clinicians felt that importance of remote care was either somewhat or very important.5 The most recent AMA survey from March 2022 reveals 85% of physicians are using telehealth in some form, specifically 93% are conducting live video visits with patients and 69% are conducting audio-only visits.6 The CDC also did some research and analysis and found a 154% increase in telehealth visits during the last week of March 2020, compared with the same period in 2019. They thought this might have been related to the regulatory waivers in place during COVID-19 which contributed to the increase in adoption of telehealth services along with public health guidance encouraging virtual visits and CDC recommendations for use of telehealth services.2 In a survey conducted by McKinsey, 76% of patients said they would be interested in using telehealth moving forward. In that same survey, they found investments in this space have tripled in terms of venture capital money being put behind digital medicine and telehealth initiatives.4 At the conclusion of the McKinsey survey, they were able to back their bold conclusion with data: “Virtual healthcare models and business models are evolving and proliferating, moving from purely ‘virtual urgent care’ to a range of services enabling longitudinal virtual care, integration of telehealth with other virtual health solutions, and hybrid virtual/in-person care models, with the potential to improve consumer experience/convenience, access, outcomes, and affordability.”4 Finally, more than 50% of respondents in a study from the Journal of Telemedicine and Telecare said they would utilize telehealth to: refill medications, prepare for an upcoming visit, review test results, or receive education.7 As such, the patient and public appetite is truly ready for this switch. With the hassles of driving, parking, checking in, copay payment arrangements, waiting for the clinician, getting set up for follow-up, testing and more, the amount of time, effort, and energy required for in-person visits is significantly more than a telehealth visit from the convenience of your smartphone, anywhere. From the larger institution standpoint, the American Hospital Association reports that as of 2017, 76% of U.S. hospitals connect with patients and consulting practitioners at a distance using video and other technology.8

Common approaches/types of telehealth Telehealth can mean many things to different populationsdbe they administrators, hospitals, clinics, payors, or patients. In short, telehealth is the connection of a healthcare clinician with a patient without them being physically present

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with each other. Using these services allows for care reception, consultation, arrange for testing, obtain prescriptions, and review diagnoses.9 The most common telehealth approach is the virtual visit. This visit type is attended by both patient and clinician (and sometimes family and caregivers, too) at the same time. It can take place via telephone, video, or live chat/ texting. Another visit type is asynchronous chatting which usually uses a webbased interface or an app to transmit a patient’s data, vitals, or other health information such as images, diagnostics, or other testing. This then allows the clinician to review the information to plan for discussion, further diagnostics or treatment at a later time. Many people refer to this as “store and forward” technology which in a lot of ways is a lot like a secure email service. The next category is remote patient monitoring which is growing at an exponential rate. With this technology, a clinician can collect, transmit, receive, and process a patient’s health data instantly, and often in real-time, from outside a traditional healthcare sitting, that is, from a patient’s home or even while they are out exercising or doing other activities. Remote patient monitoring allows for ongoing condition monitoring and chronic disease management and can be synchronous or asynchronous, depending on what is needed. Remote patient monitoring also lends itself nicely to machine learning and artificial intelligence applications to allow for processing and intake of the data in a way that prevents data overload for the clinician and the elimination of many false positives for data which may be abnormal. The final general category is other technology-enabled modalities. These modalities allow for physician-to-physician discussion and consultation, evaluation if imaging (such as echocardiograms, ECGs, and X-ray modalities), digital diagnostics (such as algorithm-based diagnostic supports), and digital therapeutics (i.e., sensors used with or without drugs for disease management). It is probably no surprise that with the above approaches, there is improved clinician access and potentially reduced time to diagnosis and treatment, costeffectiveness, improved quality, and works to satisfy healthcare consumer demand. Of course, not all visit types are best for telehealth. Visit types which may better suited for direct in person visits include critical care, trauma, visits where diagnostic testing is needed urgently, abdominal or chest pain, eye complaints, dental complaints, gynecologic or obstetric complaints, high complexity medical cases, and visits where the physical exam would change the direction or strategy of the visit.10

Telemedicine versus telehealth As you probably could guess, telehealth and telemedicine definitions encompass very similar services. Most of these services include everything we already do over electronic means such as medical education, e-health patient

4 Emerging Practices in Telehealth

monitoring, patient consultation via video conferencing, health wireless applications, transmission of image medical reports, and many other patient information transfer services. Technically speaking, telemedicine is a subset of telehealth. Telehealth is a broad term that includes all health services provided using telecommunications technology, whereas the term “telemedicine” refers specifically to clinical services provided through these means.11 The widely references California Telehealth Resource Center defines telehealth as follows: Telehealth is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies.12

The benefits of telehealth There are many benefits to telehealth for both physicians and patients. The major benefit is markedly improved access to care for patients and easier ways to deliver care from anywhere for clinicians. No matter the weather, distance, or location, near instant access to live care can be achieved with technology (provided it is accessible via telephone, Internet, or other communications channel). Telehealth not only improves patient access, it also extends the geographic reach and expertise of physicians and health facilities as a whole. With the looming provider shortages around the world, telehealth can help address access. It can also provide millions of people in both rural and urban areas access to safe, effective, and appropriate care, especially specialty care for rare diseases when and where it is needed. Telehealth can also help with cost efficiency. Cost containment is on the lips of health payors daily. In fact, reducing the cost of healthcare is one of the strongest motivators to fund and adopt virtual care technologies.9 Telehealth allows for better management of chronic diseases, shared health professional staff, less or no travel time, and could even permit fewer or shorter hospital stays. Quality is always a major aim of any medical approach. Studies have consistently shown that the quality of healthcare services delivered via telehealth is as good as those in person.9 For specialist caredoften mental health and ICU careddtelehealth delivers a superior product with perhaps better expertise, with greater outcomes and patient/family satisfaction. Consumer demand for easy and convenient care is on the rise. The cost of transportation, gas, energy, parking, and lost productivity are key drivers of convenience. The use of telehealth eliminates most travel time and related stresses for the consumer. Over the past decade or more, research has documented consumer satisfaction and support for telehealth services.9

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One obvious advantage of telehealth for both patients and clinicians is the reduction in spread of communicable diseases such as COVID-19.13 The other advantages for patients are reductions in lost productivity time from work, decreased travel cost, decreased wait time for visits, and increased specialist access, especially for those not available in more remote regions.

Choosing a vendor þ platforms Choosing the right platform and vendor for your telehealth implementation is important for a variety of reasons. The platform you choose will allow you and your institution to offer features to patients from teleconferencing, audio discussion, chats, secure messaging, lab and diagnostic test review, and much more. Also, the platform you use may easily integrate into your electronic medical record and/or scheduling system or may work alongside your EMR and may only facilitate communication. As you might imagine, costs may change with more features and integration, so know your budget before you get to far down the road with any one platform or vendor. One of the barriers to telehealth is the technology itself. Is important to choose a platform that your clinicians can easily use and access and understand the basic troubleshooting for patients. Equally important is choosing one that the patients can easily get on without too many steps, clicks, and setting selections. Consumer/patient computers along with institutional security policies can often interfere with a well-intentioned video visit if not planned for ahead of time. Speaking of security, you want a platform that is HIPPA compliant, and won’t allow for malicious file exchange, covert system monitoring, and is reasonably able to fend off unauthorized access (i.e., preventing a third party from entering or accessing your visit with a patient). Many discussions will be had with your institutional team about “friction” or barriers to use. The goal is to have as much of a “frictionless” experience as possible which means that setting up a visit with a patient should not require downloading of software, passwords, accounts, usernames, and other measures which could reduce the likelihood of a successful encounter. As an example, Zoom, a widely used video conferencing and meeting software is often used in health care and requires the use of an app (which usually requires a download from an app store provider which usually requires an account/password), a special link, multiple clicks for connection to video, and then another few clicks for audio connection, whereas Doximity and others send a single link to a patient (over text, which can require some configuration for patients who don’t text regularly) which can be clicked and connected with that one click. Further to this, understanding if a solution is cloud-based or requires onsite servers (or uses local servers to the company) is important. With most cloud-based solutions, there should be little of any tech support, trouble shooting, uptime/downtime issues, or software to install.14 Along this theme,

6 Emerging Practices in Telehealth

FIGURE 1.1 The CMS guide to telehealth makes specific note of vendors which provide HIPAA complaint communications. From: CMS: Telehealth For Providers: What You Need To Know. Article available from: https://www.cms.gov/files/document/telehealth-toolkit-providers.pdf accessed 3/5/22.

FIGURE 1.2 Nontraditionally HIPAA complaint platforms could be used during the pandemic “emergency” declaration. From: CMS: Telehealth For Providers: What You Need To Know. Article available from: https://www.cms.gov/files/document/telehealth-toolkit-providers.pdf accessed 3/5/22.

platforms which are frictionless won’t use dedicated IT resources to a great extent among your users which is always a plus since it saves time and money. The CMS guide to telehealth makes specific note to the below list of vendors which provide HIPAA complaint communications: They also specifically mention that nontraditionally HIPAA complaint platforms could be used during the pandemic “emergency” declaration like: A couple of recent review sites make some suggestions for platforms that might serve certain populations better.15 Zoom for healthcare, besides being HIPAA compliant allows for group video conferences, high resolution video in poor service areas, on screen annotations, integration with some EMRs like EPIC. Some platforms like Healthie use zoom, but then offer EMR-like

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capabilities. Doxy.me requires no download and has some more advanced check-in and waiting room workflow features and may offer one of the more frictionless approaches. Webex, like Zoom, offers a well-known platform for conferencing to patients. GoToMeeting also offers the same functionality as its well-known business platform along with screen sharing, recording, and conference calling for audio-only approaches. Mend offers the usual communications approaches, plus text messaging, appointment reminders, selfscheduling, and more. AMC health offers connections to some Bluetooth enabled sensors and devices and has some tools for managing research populations. SwyMed is an option for ultralow-bandwidth applications and works for home-monitoring and other situations including emergency and firstresponder use. There also even more emerging services which can be found online (see the reference for more).16 In short, it makes sense to “kick the tires” and use the above information to choose wisely for your institution.

Setting up for telehealth Once you select a telehealth platform, the next part is integrating it into your practice and workflows. There are several workflow points which should be considered from before your patient is on your platform to following up after the visit is completed.10 Just like for in-person visits, every aspect of the visit from registration and intake to care delivery to follow-up needs have a plan in place. Table 1.1. Below provides some important points for consideration. Since many clinicians have not had virtual visits regularly, it is important to coach your clinical team on how to make the visit look right, feel high-quality, and authentic. Table 1.2 has some important tips for success in this arena.

Tips for success Like you would in a normal in-person visit, maintain a normal pace of speech. Talk slowly enough that the patient can understand you and consider taking time to assess for uptake and understanding. You may need to take longer pauses than you would during an in-person visit as there could be a technology delay preventing an immediate responsedthink of the newscasters transmitting from parts of the world with less well-developed technologydthat delay is important. Always consider using empathetic word choices and even nod along as your patient talks to show you are engaged and care about what they are saying. Your facial expressions should match what you are saying. When you are listening, have an empathetic and engaged expression. Just like in real life, running late can happen even on telehealth. It’s always a good idea to have a way to reach out to a patient, either on your platform or via some other mechanism to let them know. This does not need to be anything extravagant: it could simply be a medical assistant of front office staff calling a

8 Emerging Practices in Telehealth

TABLE 1.1 Workflow implementation points. Getting your telehealth going: workflow and operations points l

When are clinicians available for telehealth appointments

l

What services are offered

l

How patients scheduledconnected to online platforms, by phone or similar

l

Where will you get patient informationdform an EMR, online secure platform or other

l

Once a patient visit is started, who greets the patient? Will an MA do an intake and attempt to get vitals remotely

l

Consent for visitsdhow will this be obtained

l

Visits conducted in other than English, or for patients with disabilities how will you work in services for interpreters, sign language, etc.

l

How you’ll facilitate access to telehealth

l

How you’ll engage, follow-up, or support a caregiver or another person who needs to assist a patient during the telehealth visit

l

How/when will you bill or collect payment?

l

Who will monitor the quality of visits and patient satisfaction?

TABLE 1.2 How to make it look right. The technical aspects of telehealth done well l

Ensure your lighting is right. If possible, conduct the visit with light placed on your face so it is illuminated, free standing and USB-powered halo lights are widely available for this purpose.

l

Improve your audio by eliminating background noise as much as possible. Consider muting yourself when you aren’t speaking.

l

Make it look rightdcheck your surroundings. Avoid having anything behind you that you wouldn’t want your patients to see, especially personal items. Reduce clutter or even set up a virtual background.

l

Dress the role! Wear appropriate clothingdno pajamas or t-shirts. You patients are expecting the same clinical quality they have come to expect in person from you.

l

Avoid vanity shotsd(limit looking at yourself on the screen, fixing your hair, adjusting your clothing etc.).

l

Be-centered! Nothing is worse than having a visit with a forehead. Ensure your head is in the center of the screen.

l

Look at the camera which looks like you are looking at the patients. Maintain proper gaze.

l

When you look down, let the patient know you’re charting or looking at their EMR data.

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patient on their phone to let them know to be on and available and the clinician will join shortly, as soon as possible. Many clinicians recommend using techniques to add warmth to your visits. The AMA recently posted some tips on this approach and even have some clinicians specific feedback such as asking to meet the family pet, or ask to be taken to the kitchen to see what they ate for lunch, or to show the thing they tripped over.17 There are a number of benefits of telehealth which can be reminiscent of the old images of the home visits doctors once made in person which can give context clues for how your patient live and understand the world they live in. The same AMA discussion on virtual visit success makes specific recommendations for improving virtual communicationsdsee Table 1.3.

TABLE 1.3 Effective phrases and communication for telehealth. AMA tips for improving communications in virtual visit Adapted from https://www.ama-assn.org/practice-management/digital/telehealth-how-bringwarmth-your-virtual-care-visits Conveying respect to the patient (“Hello, Mr. Smith”). Introducing the technology for the virtual visit. Collaboratively setting the agenda. Making an empathic statement (“I hear your worry”). Eliciting patient narrative (“Tell me more”). Using reflective listening (“You have said .“). Sharing information with the patient. Collaboratively developing a plan. Confirming a patient’s understanding by asking them to share what they plan to do going forward. Providing appreciative closure (“I’m glad you scheduled this visit”). Establishing the relationship (“Re you new to virtual care?”). Displaying nonverbal empathy. For example one physician likes to put her hand over her heart and lean into the camera to let a patient know that she is listening and “all in” on the visit. Acknowledging the situation (“I am sorry you feel ill”). Validating feelings (“that is painful”). Naming emotions (“You must feel .“). Developing the relationship (“It was good to talk to you Mr Smith”).

10 Emerging Practices in Telehealth

A short primer on basic billing for telehealth Your telehealth visits will be rewarding and fill so many gaps in traditional inperson care that have been outlined above. However, to be successful reimbursement and billing need to be well-implemented. Currently, telehealth visits are reimbursed at the same level of in-person visits which is good news. For those institutions that are considered hospitals, though, your administration will likely notice that the facility fee cannot be billed on these visits which makes some systems less favorable toward the virtual visits. For outpatient facilities, this parity in reimbursements allows for more freedom from the clinicians to perform services from anywhere (provided they are licensed in the appropriate locale). There is emerging legislation that provides guidance for local and national billing policies with included rules, and more of this will be covered in this book’s billing chapter.

Welcome to telehealth In our introductory chapter, the basics of telehealth, statistics on its use and implementation, its benefits, implementation, approach, and tips for success were covered. As the book progresses, we will take an even deeper dive into many aspects of this rapidly growing approach and telehealth ecosystem.

References 1. What is Telehealth? Department of Health and Human Services, https://telehealth.hhs.gov/ patients/understanding-telehealth/?gclid¼EAIaIQobChMI4-Wf-bCg9gIVZQp9Ch2V5QGpEAAYASAAEgJZRPD_BwE accessed 2/27/22. 2. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic d United States, JanuaryeMarch 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1595e1599. https://doi.org/10.15585/mmwr.mm6943a3external. 3. Fortune Business Insights; 2021. Article available from: https://www.fortunebusinessinsights. com/industry-reports/telemedicine-market-101067. accessed Feb 2022. 4. Bestsenny O., Gilbert G., Harris A., et al. Article available from: https://www.mckinsey.com/ industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollarpost-covid-19-reality [Accessed January 2022] 5. American Medical Association. Article available from: https://www.ama-assn.org/system/ files/2020-02/ama-digital-health-study.pdf; 2020. accessed Feb 2022. 6. American Medical Association. Telehealth Resource Center: Research Findings; 2022. https://www.ama-assn.org/practice-management/digital/telehealth-resource-center-researchfindings. 7. Ebbert JO, Ramar P, Tulledge-Scheitel SM, et al. Patient preferences for telehealth services in a large multispecialty practice. J Telemed Telecare. January 2021. https://doi.org/10.1177/ 1357633X20980302. 8. AHA Telehealth Factsheet. Article available from: https://www.aha.org/factsheet/telehealth; February 2019. accessed 3/5/22.

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9. Teleheath; Definining 21st Century Care. American Telemedicine Association. Article available from: https://www.americantelemed.org/resource/why-telemedicine/,accessed 3/5/22. 10. CMS: Telehealth For Providers: What You Need To Know. Article available from: https:// www.cms.gov/files/document/telehealth-toolkit-providers.pdf accessed 3/5/22. 11. eVisit: What is Telemedicine: Article available from: https://evisit.com/resources/what-istelemedicine/. accessed 3/5/22. 12. California Telehealth Resource Center: What is Telehealth. Article available from: https:// www.caltrc.org/get-started/what-is-telehealth/. accessed 3/5/22. 13. HHS: What is Telehealth Article available from: https://telehealth.hhs.gov/patients/understandi ng-telehealth/?gclid¼EAIaIQobChMIrJPz1Lql9QIVR25vBB2KXQ6aEAAYAiAAEgLMPfD_ BwE accessed 3/5/22. 14. eVisit: 15 Questions to Ask Your Telemedicine Vendor. Article available from: https://blog. evisit.com/virtual-care-blog/15-questions-ask-telemedicine-vendor accessed 3/5/22. 15. The 5 Bets HIPPA Compliant Telehealth Tools. Article available from: https://www. gethealthie.com/blog/the-5-best-hipaa-compliant-telehealth-tools accessed 3/5/22. 16. Best Telemedicine Software of 2022: TechRadra. Article available from: https://www. techradar.com/best/best-telemedicine-software accessed 3/5/22. 17. Henry TA. AMA: Telehealth: How to Bring Warmth to Your Virtual Care Visits. Article available from: https://www.ama-assn.org/practice-management/digital/telehealth-how-bring-warmth-yourvirtual-care-visits accessed on 3/5/22.

Chapter 2

Telehealth technology infrastructure and implementation strategies Aradhana Verma1, Lindsay Brooker2, Heather Hitson2 and David Cho3 1 Department of Medicine, UCLA Health, Los Angeles, CA, United States; 2Connected Care, UCLA Health, Los Angeles, CA, United States; 3Department of Medicine, Division of Cardiology, UCLA Health, Los Angeles, CA, United States

Introduction Telehealth is a powerful tool with the capability to modernize healthcare delivery. As more clinical and nonclinical services transition online to a virtual model, the information technology (IT) infrastructure supporting telehealth is critical for successfully implementing and scaling digital solutions. There are common core technologies required to virtually deliver care across healthcare clinicians, but unique differences to consider depending on the type of healthcare organization and care delivery model. Understanding key principles to evaluate and select the optimal telehealth solution for the healthcare organization or clinician is an essential component of any telehealth implementation plan. This chapter’s goals will be to help you: l

l

l l

Understand the changing landscape of telehealth since the COVID-19 pandemic Understand the technical and staffing requirements for successful telehealth implementation plans Evaluate the quality of available telehealth solutions Learn telehealth implementation strategies for various healthcare delivery models

The Centers for Medicare and Medicaid Services (CMS) defines telehealth as “the exchange of medical information from one site to another through electronic communication to improve a patient’s health.”1 This broad definition includes video encounters that utilize synchronous, two-way audio-video communication between a patient and healthcare provider, telephone encounters and asynchronous secure messaging. Traditionally, telehealth lacked widespread adoption for Emerging Practices in Telehealth. https://doi.org/10.1016/B978-0-443-15980-0.00010-7 Copyright © 2023 Elsevier Inc. All rights reserved.

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several reasons, including lower reimbursements, geographic restrictions, inadequate technological capabilities by healthcare clinicians and institutions, and variation in policies and licensure by individual states.2 Prior to the pandemic, barriers to adopting telehealth had been incrementally lowered through broader telehealth reimbursement codes enacted by CMS, as well as legislation passed by several states granting telehealth parity of reimbursement with traditional in-person visits.3 However, telehealth was not widely adopted, representing less than 1% of all primary care encounters in February 2020.4 In response to the COVID-19 pandemic, CMS and the Department of Health and Human Services removed most of the financial and geographic barriers previously limiting this technology.5 Healthcare organizations, clinicians and patients rapidly developed and deployed telehealth solutions on a trial-and-error basis. By April 2020, nearly half (43.5%) of all outpatient primary care encounters were conducted through telehealth.4 Between April 2021 and October 2021, telehealth utilization has stabilized to represent approximately 20%e25% of healthcare encounters.6 Accelerated by the global pandemic, telehealth has matured into a safe and broadly accepted model of care. The IT standards and infrastructure to support this transformation will also continue to develop as more healthcare services transition to a virtual-only or hybrid model. The ability to provide care virtually affords patients with the flexibility and convenience to fit their medical needs into their daily lives. The patient and provider relationship will similarly change, with increasing amounts of patient-generated data reconciled through touchpoints with clinicians that occur online synchronously, asynchronously, and through the standard office visit. Ensuring that technologyenabled services are strategically designed and implemented to meet the needs of all stakeholders through this transition is paramount.

Universal technical infrastructure requirements of telehealth Telehealth infrastructure requirements vary depending on the services provided, but certain technical components are universal. These are outlined by the Office of the National Coordinator for Health IT (ONC) and include7 l l l l

Access to broadband internet Imaging technology (audio-video capabilities) Technical support staff Staff training

Access to broadband internet Patients and clinicians who connect through two-way audio and video communication will require a broadband internet connection. In 2015, the Federal Communications Commission updated its definition for broadband as

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always-on high-speed internet access capable of at least 25 megabits per second (Mbps) download and 3 Mbps upload speeds. Broadband internet can be delivered via satellite, coaxial cables, fiberoptic cables, digital subscriber line (DSL), broadband over power lines or wireless cellular connections. It may be tethered to a physical location such as a home or office, or portable through mobile devices. For reference, the minimum standards for mobile 4G, the most common wireless coverage in the United States, are defined by the FCC as providing 5 Mbps download and 1 Mbps upload speeds. The newer 5G standard, which has a smaller geographic footprint, is able to deliver high-level broadband connection speeds with 300þ Mbps download speeds and 100þ Mbps upload speeds.8 As virtual care options become more widespread with higher quality video streaming, along with future virtual and mixed reality offerings, the need for universal broadband internet access is imperative to reduce the risk of widening the digital divide and worsening health inequity.

Disparities in broadband internet access Improving widespread access to broadband internet in order to prioritize equitable care is critical while telehealth services continue to grow. Without the necessary technology infrastructure in place, a lack of available high-speed internet can hinder the implementation and expansion of telehealth services that require a strong virtual connection between patients and clinicians. At the time of the FCC’s updated broadband internet definition in 2015, approximately 55 million Americans (nearly 17% of the population) lacked access to a high-speed internet connection, which disproportionately affected half of all rural Americans and nearly two thirds of residents on tribal lands and U.S. territories.8 Furthermore, a 2020 survey by the California Pan-Ethnic Health Network (CPEHN) targeting underrepresented populations and those with limited English proficiency revealed that 62% of respondents said they did not have a strong enough internet connection or bandwidth, and 57% stated that they did not have enough cell phone minutes to effectively utilize telehealth.9 Accordingly, the federal government enacted the Infrastructure Investment and Jobs Act into law effective November 2021, allocating $65 billion for broadband access to improve internet services for rural areas, low-income families, and tribal communities.10 Most of the funding will be available to states via grants, and a significant portion will also be used to establish the Affordable Connectivity Program which provides direct broadband subsidies for eligible households. The FCC also initiated a Connected Care Pilot Program that provides up to $100 million from the Universal Service Fund over a 3-year period to selected applicants. The program covers 85% of eligible costs of broadband connectivity, network equipment and information services necessary to provide connected care services to the intended patient population.11 While providing funds to upgrade the basic infrastructure for telehealth is a necessary first step, numerous systemic barriers leading to health inequity

16 Emerging Practices in Telehealth

remain. A deeper exploration into increasing access and decreasing disparities with telehealth is described in a later chapter.

Imaging technology (audio-video capabilities) Broadband internet is the foundational IT component required for telehealth with imaging technology. Additional requirements include a webcam, microphone, speakers, and a computer or mobile device with sufficient processing power and compatible operating system. However, the features of imaging technology platforms that provide synchronous two-way audio-video capabilities vary significantly. The minimum bandwidth requirements depend on numerous factors, including minimum download and upload speeds, number of features utilized and simultaneous connections. Bandwidth usage will vary based on the resolution, frames per second, make and model of web camera utilized, number of simultaneous users, local network activity, screen sharing, and whether users are actively both transmitting and receiving video, or receiving either video or audio only (Table 2.1).12,13 While HHS waived enforcement for requiring imaging technology solutions to be compliant with the Health Insurance Portability and Accountability Act (HIPAA) during the pandemic in order to preserve access to healthcare services in good faith, this exemption is unlikely to remain in effect after the COVID-19 national emergency ends.14 HIPAA-compliant solutions for audio-video, audioonly, and secure messaging should be mandatory for all telehealth solutions.

TABLE 2.1 Typical minimum bandwidth requirements for two-way audiovideo imaging technology. 1:1 video calling

Download speed

Upload speed

High-quality video

600 kbps

600 kbps

720p HD video

1.2 Mbps

1.2 Mbps

1080p HD video

3.8 Mbps

3.0 Mbps

High-quality video

1.0 Mbps

600 kbps

720p HD video

2.6 Mbps

1.8 Mbps

1080p HD video

3.8 Mbps

3.0 Mbps

No video thumbnail

50e75 kbps

50e75 kbps

With video thumbnail

50e150 kbps

50e150 kbps

Group video calling

Screen sharing

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Typically, the protection of personal health information requires end-to-end encryption, business associate agreements to ensure accountability, and activation of privacy and security features of the platform.15

Technical support staff As telehealth requires a reliable internet or phone connection, along with functional equipment for both clinician and patient, providing technical support is another key infrastructure component. Technical support staff should be readily available to troubleshoot and assist patients, clinicians, clinical staff and the telehealth platform as issues arise.

Patients Patients may experience difficulty acclimating to telehealth, particularly those without stable high-speed internet connections and low digital literacy. If the telehealth solution is utilizing a smaller mobile device screen, visual and auditory impairments will be important to consider as well during two-way synchronous communication. Certain patients that may be at high risk for experiencing technical difficulties can be identified by clinical support staff or through electronic health record (EHR) and clinical intake tools. One study found that a simple risk score derived from EHR variables could predict patients at high risk for experiencing difficulty logging into their scheduled telehealth appointment. A score-based system was utilized, with a higher aggregated score assigned for those without: 1. An active health portal account 2. A lack of electronic check-in within the previous 7 days 3. No prior video visit within the last 3 months Patients identified as high risk for experiencing technical challenges were contacted by IT to assist with preparation for their upcoming telehealth appointments.16 Ultimately, each organization or practice will evaluate how to best optimize their workflows. Overcoming the commonly anticipated technical challenges, however, is a shared opportunity to improve equality of access to healthcare, avoid delays in clinical workflows, and enhance patient satisfaction.

Clinicians Clinicians and clinical staff will require technical support mostly during the set-up of a secure network to protect sensitive patient data and during the telehealth encounter. As clinicians and staff may be working remotely during telehealth encounters, ensuring that proper security measures for home networks, personal or work computers and mobile devices are in place to maintain patient privacy is critical.

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Technical support staff Deciding upon internal technical support from IT staff within the healthcare organization or external support through the telehealth vendor will also be important factors to consider when deciding upon a vendor. Finally, technology services are constantly evolving, and customer support availability along with timely software updates and added features should be carefully evaluated. Staff training Training clinicians and staff to develop optimized clinical workflows are important to maintain operational efficiency. Clinicians and nonclinicians alike must work both independently and in tandem to ensure a high quality of care and satisfactory patient experience. Implementing telehealth services may require a redesign of longstanding traditional clinic workflow models. Consequently, the initial cost of telehealth not only includes the initial investment in technological infrastructure, but also in the recruitment and training of staff coordinating telehealth efforts. In a phone conversation with Dr. Anshu Abhat on March 1, 2022, she highlighted the importance of investing in a strong team, stating that “. we spend a lot of money on technology, but not on people. We need to invest in people to help our patients.” The Agency of Healthcare Research and Quality finds that only 12% of U.S. adults have sufficient literacy to navigate the health care system, and even these individuals can struggle where they are sick.17 Studies demonstrate that community health care workers, care navigators, and health educators are important allies in helping patients navigate the complex health care system.18e20 The Department of Health Services in Los Angeles County utilizes a team of health technology navigators who work with multiple departments, medical groups, durable medical equipment suppliers, and doctors to help coordinate care. With the uptake of telehealth services, many of these roles have expanded or shifted to a remote service delivery model. Staff members assist clinicians and patients with telehealth services and also lead recurring training sessions for staff on various virtual technologies. Another consideration is to form a group of “super users and champions” who gather feedback and report back to the virtual platform vendors to achieve patient-centered, user friendly designs of current interfaces.21 While technology is the backbone of telehealth, dedicated staff helping navigate technological challenges and advising others on how to best leverage the technology is equally important. The focus on telehealth clinical workflow implementation is further described in more detail in a following chapter.

Digital literacy Low digital literacy remains a barrier for equitable telehealth adoption. Improving digital literacy should be prioritized as the fifth cornerstone of Telehealth infrastructure requirements. The rapid deployment of telehealth

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during the COVID-19 pandemic has not fully accounted for the needs of underrepresented populations such as Black, Latinx, indigenous, rural, older adult, and low-income adults who experience barriers to virtual care at higher rates. A recent study of telehealth implementation at UCSF Medical Center and Zuckerberg San Francisco General Hospital and Trauma Center found that while video and telephone visits dramatically increased with COVID-19, the proportion of visits with adults with limited digital literacy significantly decreased, including among patients 65 years of age or older, non-English language patients and those on Medicare or Medicaid.22 These findings suggest that improving digital literacy and creating a user-friendly experience to connect with healthcare clinicians should be incorporated into all telehealth implementation plans.

TABLE 2.2 Recommended bandwidth for different types of healthcare clinicians. Type of provider

Minimum recommended bandwidth speeds

Single physician practice

4 Mbps

Small physician practice (2e4 clinicians)

10 Mbps

Nursing home

10 Mbps

Rural health clinic (5 clinicians)

10 Mbps

Large physician practice (5e25 clinicians)

25 Mbps

Hospital or large healthcare organization

100 Mbps

Evaluating telehealth platforms Implementing, maintaining, and improving telehealth services are expensive, time-consuming, and challenging to execute. Not all health systems require or should have the same infrastructure, so a formal needs assessment before investing in new infrastructure is important. Additionally, the following questions outlined in Table 2.3 should be considered to identify the most important telehealth needs for the healthcare organization and its patient populations. A thoughtful and deliberate plan to measure success across the following domains should be universal considerations for all healthcare care delivery models:23

20 Emerging Practices in Telehealth

TABLE 2.3 Key questions for telehealth program development. Telehealth Leadership Team l

How will telehealth help our organization achieve our strategic goals and support health equity?

l

Who are the key members of the telehealth leadership team, and which stakeholders need to be aligned in the planning, approval and implementation phases?

l

What are the technological and operational requirements?

l

What is the budget for initial investment, maintenance, and upgrades of technology platforms?

l

Where will the technology be located?

l

How will we utilize telehealth to generate revenue or enhance value-based care with added cost savings?

l

How will we define and measure success?

l

Who will lead our plan, do, check, act (PDCA) quality assessment and improvement cycles

l

How will we ensure data security and HIPAA compliance?

Telehealth user experience l

Which clinicians will be using this system?

l

Who are the patient populations we serve?

l

What kinds of technology (e.g., smartphones, computers) will the patient population have access to?

l

What are the broadband internet speeds in the area and is it equally distributed in the region?

l

What is your practice’s clinic workflow?

l

How will this new service integrate into current operations and clinical service lines?

1. 2. 3. 4. 5. 6.

Access to care Patient, family and caregiver experience Clinician experience Clinical outcomes, quality and safety Financial and operational impact Health equity

Prior to vendor selection, one should also ensure that the recommended minimum broadband connections for two-way audio-video encounters, telephone or Voice over Internet Protocol (VoIP) for audio-only encounters, and secured messaging platform for asynchronous electronic communications are in place. Table 2.2 describes the minimum recommended bandwidth speeds for

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different types of healthcare clinicians depending on organization size and needs.24 Healthcare organizations and practices can directly contract with a third-party vendor, build an in-house platform, or form partnerships to codevelop programs. According to Deloitte, “partnerships with technology companies, disrupters, and others in the community may help develop innovative care delivery models or nonhealthcare services and capabilities that an organization could not have done on its own.”25 The hardware needed for clinicians and patients depends on the telehealth services provided. For example, if a physical exam is not required, a phone or mobile device may be adequate. Some clinicians have advocated prioritizing smartphone technology to increase access, highlighting that the use of specific equipment with dedicated cameras and screens and the need for institutional infrastructure makes the deployment and use of these systems expensive and rigid. Alternatively, a desktop system provides a more comprehensive experience, allowing the provider to visually assess the patient and their environment. If telehealth is utilized for group sessions with multiple users with live video and audio streaming, the computing power and broadband speeds required will increase accordingly. Telemedicine mobile carts are a good option for ancillary counseling services, which may also be conducted in a group format for consultations such as nutrition and diabetes education. Telehealth software platforms are built to enable synchronous or asynchronous clinician and patient communications while protecting patient privacy. Larger healthcare organizations may utilize telehealth platforms with full EHR integration, or as a stand-alone solution without EHR integration. In the latter case, clinicians use their existing EHR to schedule patients, document encounters, and bill for telehealth visits. Depending on the solution, asynchronous messaging communication between patients and clinicians can occur within either the telehealth platform or EHR. Each telehealth vendor has a common set of core capabilities, but may vary depending upon available features and technical support services provided. In general, added features for telehealth platforms will correlate with higher costs and internet bandwidth. Therefore, it is imperative to identify and separate the “must-have” features from the “nice-to-have” features as one evaluates various telehealth vendors. This will ensure that the vendor selected fits within the organization’s telehealth implementation strategy and budget. Prioritizing platforms with a simple and intuitive user interface and user experience (UI/UX) is key to facilitate adoption by patients and clinicians. A 2017 study evaluated the usability of four home-based telemedicine software platforms: Doxy.me, Inc. (Rochester, NY), Vidyo, Inc. (Hackensack, NJ) VSee, Inc. (Sunnyvale, CA) and Poly, Inc. (San Jose, CA). The study found that usability problems with installation and account creation led to high mental demand and task completion time, suggesting the participants preferred a system without such requirements. The majority of the usability issues were identified at the telemedicine initiation phase.26 The contrast between business

22 Emerging Practices in Telehealth

video conferencing applications and telehealth are notable, as “. conferencing workflows are built for business. They are outbound, provider-centric, and simple. They are designed to navigate people to a virtual meeting room where the provider is located . Patient consulting workflows on the other hand are in-bound, patient-centric and often complex. Designs need to align with the way health care works, and how people approach a service, as opposed to a room.27 When assessing vendors for telehealth platforms, it may be beneficial to consider product demos that include input from the leadership team, IT staff, clinicians and patients. A standardized questionnaire that has been validated to assess satisfaction, known as the Telehealth Usability Questionnaire, may provide a standardized comparison among multiple vendors.28 Additionally, when entering into an agreement with a vendor, it will be important to establish a long-term relationship and partnership. However, any such agreement should maintain the flexibility to pivot to an alternative solution if the platform is not meeting expectations.

Implementation strategies in areas without reliable broadband internet and low digital literacy Prioritize telephone encounters and consider low broadband options Federally Qualified Health Centers (FQHCs) provide comprehensive care to underserved patients across the country. They have been on the front lines of rapidly developing and implementing telehealth services given the disproportionate impact of the COVID-19 pandemic on its patient population. Federal data show that telehealth use accounted for over 80% of FQHC visits in the early months of the pandemic and 47% of visits in 2020.29 Another study measuring telehealth use among FQHCs in California during the first 6 months of the pandemic found that telephone visits constituted almost half of all primary care visits and more than 60% of behavioral health visits.30 While FQHCs and safety net hospitals have rapidly advanced access to telehealth services, low-income patients face unique barriers to successfully completing video visits, and audio visits predominate telehealth services. Los Angeles County (LAC) data shows 70% of patients who have access to their electronic portal do so via their mobile devices, which Pew Research describes as “smartphone dependence” among low-income and minority populations.21,31 Casillas et al. calls for internet strategies for safety net populations that are “mobile first,” advocating for vendors to prioritize the development of their mobile application over the desktop version of the portal.21 A strategy that centers around audio visits meets patients where they are and leverages easily accessible technology. In a phone interview with Matthew Ware on February 23, 2022, the quality improvement coordinator at Venice

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Family Clinic, an FQHC in LAC, he shared that there were significantly fewer barriers to implement audio visits in the beginning of the COVID-19 public health emergency. Clinicians did not require dedicated equipment such as webcams or desktop screens, consenting patients for phone visits was simpler, and technical difficulties were more manageable. Dr. Anshu Abhat from the Department of Health LAC also noted in her phone interview on March 1, 2022 that video integration continues to be a challenging issue for her safety net population. To ensure a seamless video visit, the county hospital schedules 30-minute “tech checks” to orient patients before their telehealth encounter. These “tech checks” require higher nursing capacity and scheduling staff. In addition to needing more resources, this correlates with findings that video integration software is often not user-friendly or catered for patients with lower education and digital literacy. A study describing the implementation of telemedicine in the U.S. Department of Veterans Affairs (VA) specialty care clinics highlight the lack of user-friendly of their video conferencing platform. Clinicians reported spending 10e15 min of the 30-minute appointment walking patients through the process to get connected over video and as a result, most switched to phone appointments.32 For areas with limited broadband, it is also prudent to use less broadband intensive telehealth services such as audio or text messaging services. For example, the Direct to Patient Tele-Behavioral Services program for Medicaid patients in 14 rural and frontier counties in Oregon offers a text-based options for behavioral therapies.33 While these types of programs innovatively offer access and patient engagement, a live two-way audio and vissual telehealth encounter does allow several advantages. Namely, the ability to perform a limited examination of the patient and read facial expressions and body language cues that allows for a more human connected experience. It is promising that new legislation and programs are helping to increase access to broadband internet at a systemic level. However, until broadband internet is universally available and patients possess a minimum level of digital literacy to facilitate telehealth with imaging technology, resource-limited settings should continue to optimize the current widespread use of telephone and text messaging to improve access to care.

Implementation strategies for enterprise healthcare organizations Identify key stakeholders and develop a leadership team for strategy planning and implementation The major stakeholders in large healthcare organizations include leaders from various departments, including operational leadership, clinicians, health IT, legal, billing, and compliance. Organizations must determine in which department telehealth will be housed to ensure accountability, facilitate communication across multiple departments, and avoid duplication of roles and responsibilities.23

24 Emerging Practices in Telehealth

As larger healthcare organizations typically undergo longer sales cycles than smaller organizations and face higher costs to purchase and maintain enterprise solutions, the need to appropriately vet and deploy a telehealth solution in a timely, cost-effective, and scalable timeline is paramount. An enterprise health system should seek out a vendor with a vested interest in remaining a long-term partner to foster a mutually beneficial relationship. Without strong organizational leadership to strategize, select the right telehealth platform, implement the program, measure success and adjust as needed, the value and efficiencies offered by telehealth will not be realized.

Pilot small but with scalability in mind With each new technology implemented, the pilot program should span a wide range of specialties, clinicians, and clinics in order to identify any potential specialty-specific technical or workflow concerns. When one large healthcare organization, UCLA Health, proceeded with a major optimization project in 2021, the pilot project consisted of roughly 30 different clinicians across multiple specialties. The information gleaned from clinicians in different settings allowed the IT team to make adjustments to the telehealth platform and prepare educational materials for patients, clinicians, and staff before the system went live. Since individuals had varying baseline levels of digital literacy and learning preferences, a diverse array of training support options was created to support clinicians and patients, including self-directed education modules, tip sheets, a technical support line, and one-on-one sessions. Similarly, in the early days of telehealth expansion, the responsibilities of supporting both patients and clinicians were shouldered by a small telehealth team within the health IT department. The team managed the workload well during the early days of piloting, but as rapid scaling began, redesigning training and technical support protocols became a top priority. With the exponential rise in telehealth demand, the team was ready to rapidly train and support the suddenly essential service when the COVID-19 public emergency order was issued. The video telehealth program at UCLA Health increased from roughly 500 visits per month to nearly 3000 per day within the first weeks of the pandemic with broad stay-at-home orders in place. Despite the small nature of the initial program, the implementation plan was set up to scale effectively. Ongoing quality improvement assessment with a thorough plan, do, check, and act (PDCA) cycle allowed for identification of key areas in which the telehealth user experience and system reliability could be improved. As a result, the overall satisfaction rose as patient and clinicians became more familiar with telehealth. As telehealth programs continue to mature, ongoing PDCA cycles will be necessary to continually the patient and clinician experience.

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Implementation strategies for individual or group clinician practices Take advantage of the ability to move quickly and rapidly identify the most reliable, cost-effective solution with least disruption to existing clinical workflows While smaller practices generally have less available capital and resources than integrated health systems to deploy a large-scale telehealth program, the ability to move nimbly is a distinct advantage. As there may be fewer leadership team members and organizational bureaucracy concerns to overcome, consensus decisions will likely occur quickly. Telehealth platforms that provide the ability to perform two-way synchronous audio and video visits at low cost and high reliability will be the key components prioritized during vendor evaluations. Additional features such as EHR integration may not be necessary if the main focus is to reliably communicate with the patient and bill for telehealth services. Many patients have capable smartphones, and telehealth vendors that provide secure, HIPAA-compliant solutions that are cost-effective and easy to set up and support with minimal burden to the practice will likely provide highest value. Clinical practices that are either individually or groupowned will have fewer specialties than a large integrated healthcare system, which will facilitate planning and workflow implementation. Finding the solution that is most reliable and cost-effective solution for the narrower focus of smaller practices will support practice revenue and minimize clinical workflow interruptions.

Implementation strategies for virtual-only services Find a specialized area that is underserved by the current market and create a service for the user that provides exceptional clinical value and high patient satisfaction The pandemic provided an opportunity for new virtual-first or virtual-only care delivery models to emerge. A Rock Health report noted that “. to drive greater engagement and consistent outcomes, telemedicine tools are now increasingly being built for specific clinical issues (e.g., autoimmune disorders, reproductive health), consumer groups (e.g., LGBTQ þ community, womenþ1), or both (e.g., adolescent behavioral health).”34 An entire industry of digital health is attempting to design the optimal user experience combining synchronous audio-video encounters with asynchronous touchpoints. Specialized virtual-care options serve diverse clinical areas such as mental health, physical therapy, chronic disease management, urgent care, dermatology, weight management among numerous other specialties. These solutions are typically directly targeting patients or partnering with payors to lower costs and increase patient access. Any implementation strategy will need to

26 Emerging Practices in Telehealth

consider state and federal regulations regarding telehealth for adequate licensing and reimbursement. Clinicians may pursue career flexibility and practice by joining an established virtual care company, or utilizing technology platforms to transition their clinical practices online. To date, these solutions generally target patients who are younger, have higher socioeconomic status, possess greater digital literacy, and have access to the necessary hardware components with reliable broadband internet connection. However, telehealth options are increasingly addressing healthcare inequities by prioritizing nonEnglish speakers, underrepresented populations, and people of color. Compared to standard telehealth platforms aimed at healthcare organizations, these virtual only solutions are typically rapidly scalable, cost-effective, accessible, and potentially more equitable. The long-term maturation of this nascent field and whether virtual-first care becomes the new standard of care in the future remains unclear.

Conclusion Prior to the onset of the pandemic, telehealth represented only a small fraction of medical care with only a few generalized solutions. Since then, telehealth has grown to comprise 20% or more of all outpatient healthcare encounters.4 The number of telehealth solutions available has exponentially increased as well with an industry focus on optimizing the user experience. However, much progress still needs to be completed to improve access to broadband internet and increase digital literacy to prevent worsening of healthcare inequities. As many healthcare organizations deployed and scaled solutions without adequate planning and preparation during the pandemic, there is an opportunity to reassess and improve upon existing telehealth programs. A team-based approach should be used to strategically develop and implement a telehealth program that can realistically increase access to care, create a favorable patient and clinician experience, monitor clinical outcomes, optimize revenue and operations, and improve health equity.

References 1. Medicare Telemedicine Health Care Provider Fact Sheet. CMS.gov. Published 2020. Accessed September 16, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-teleme dicine-health-care-provider-fact-sheet. 2. Adler-Milstein J, Kvedar J, Bates DW. Telehealth among US hospitals: several factors, including state reimbursement and licensure policies, influence adoption. Health Aff. 2014;33(2):207e215. https://doi.org/10.1377/hlthaff.2013.1054. 3. Bill TextdAB-744 Health Care Coverage: Telehealth. Accessed March 16, 2022. https://leginfo. legislature.ca.gov/faces/billTextClient.xhtml?bill_id¼201920200AB744&utm_ source¼TelehealthþEnthusiasts&utm_campaign¼c5351f63d3-EMAIL_CAMPAIGN_2019_ 10_15_04_02&utm_medium¼email&utm_term¼0_ae00b0e89a-c5351f63d3-353229733.

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4. Department of Health and Human Services. Medicare Beneficiary Use of Telehealth Visits: Early Data from the Start of the COVID-19 Pandemic. Accessed September 17, 2020. https:// aspe.hhs.gov/reports/aspe-issue-brief-medicare-beneficiary-use-telehealth-visits-early-datastart-covid-19-pandemic. 5. Centers for Medicare and Medcaid Services. COVID19 Emergency Blanket Waivers for Healthcare Providers. Accessed September 16, 2020. https://www.cms.gov/files/document/ summary-covid-19-emergency-declaration-waivers.pdf. 6. Karimi M, Lee EC, Couture SJ, et al. National Survey Trends in Telehealth Use in 2021: Disparities in Utilization and Audio vs. Video Services. 7. What are the Technical Infrastructure Requirements of Telehealth? | HealthIT.gov. Accessed March 16, 2022. https://www.healthit.gov/faq/what-are-technical-infrastructure-requiremen ts-telehealth. 8. 2015 Broadband Progress Report | Federal Communications Commission. Accessed April 13, 2022. https://www.fcc.gov/reports-research/reports/broadband-progress-reports/2015broadband-progress-report. 9. Equity in the Age of Telehealth: Considerations for California PolicymakersdCalifornia Pan-Ethnic Health Network. Accessed April 13, 2022. https://cpehn.org/publications/equityin-the-age-of-telehealth-considerations-for-california-policymakers/. 10. Rep. DeFazio PA [D-O-4]. H.R.3684 - 117th Congress (2021e2022): Infrastructure Investment and Jobs Act. 117th Congress. 2021. 11. Connected Care Pilot Program | Federal Communications Commission. Accessed April 14, 2022. https://www.fcc.gov/wireline-competition/telecommunications-access-policy-division/ connected-care-pilot-program. 12. What are the Minimum Bandwidth Requirements for Sending and Receiving Video in Cisco Webex Meetings? Accessed April 14, 2022. https://help.webex.com/en-us/article/ WBX22158/What-are-the-Minimum-Bandwidth-Requirements-for-Sending-and-ReceivingVideo-in-Cisco-Webex-Meetings?. 13. Zoom System Requirements: Windows, macOS, LinuxdZoom Support. Accessed March 17, 2022. https://support.zoom.us/hc/en-us/articles/201362023-Zoom-system-requirements-Win dows-macOS-Linux. 14. Notification of Enforcement Discretion for Telehealth | HHS.gov. Accessed April 14, 2022. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notifica tion-enforcement-discretion-telehealth/index.html. 15. The Security Rule | HHS.gov. Accessed April 17, 2022. https://www.hhs.gov/hipaa/forprofessionals/security/index.html. 16. A Simple Way to Identify Patients Who Need Tech Support for Telemedicine. Accessed April 17, 2022. https://hbr.org/2021/08/a-simple-way-to-identify-patients-who-need-tech-sup port-for-telemedicine. 17. AHRQ Health Literacy Universal Precautions Toolkit. 18. Towfighi A, Cheng EM, Ayala-Rivera M, et al. Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: secondary stroke prevention by uniting community and chronic care model teams early to end disparities (SUCCEED). BMC Neurol. 2017;17(1):24. https://doi.org/10.1186/ s12883-017-0792-7. 19. Brownstein JN, Chowdhury FM, Norris SL, et al. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007;32(5):435e447. https:// doi.org/10.1016/j.amepre.2007.01.011.

28 Emerging Practices in Telehealth 20. Allen JK, Dennison-Himmelfarb CR, Szanton SL, et al. Community outreach and cardiovascular health (COACH) trial. Circ Cardiovasc Qual Outcomes. 2011;4(6):595e602. https://doi.org/10.1161/CIRCOUTCOMES.111.961573. 21. Casillas A, Abhat A, Mahajan A, et al. Portals of change: how patient portals will ultimately work for safety net populations. J Med Internet Res. 2020;22(10):e16835. https://doi.org/ 10.2196/16835. 22. Nouri S, Khoong EC, Lyles CR, Karliner L. Addressing equity in telemedicine for chronic disease management during the covid-19 pandemic. New Engl J Med Catal Innov Care Deliv. 2020. https://doi.org/10.1056/CAT.20.0123. Published online. 23. American Medical Association. Telehealth Implementation Playbook; 2022. Published online https://www.ama-assn.org/terms-use. Accessed April 17, 2022. 24. What is the Recommended Bandwidth for Different Types of Health care Providers? | HealthIT.gov. Accessed April 18, 2022. https://www.healthit.gov/faq/what-recommendedbandwidth-different-types-health-care-providers. 25. Hospital Mergers and Acquisition Trends | Deloitte Insights. Accessed April 18, 2022. https://www2.deloitte.com/us/en/insights/industry/health-care/hospital-mergers-acquisitiontrends.html. 26. Agnisarman SO, Chalil Madathil K, Smith K, Ashok A, Welch B, McElligott JT. Lessons learned from the usability assessment of home-based telemedicine systems. Appl Ergon. 2017;58:424e434. https://doi.org/10.1016/j.apergo.2016.08.003. 27. Enabling Mainstream Video Call Access to Existing Health Services (And Why Video Conferencing Can’t Cut It) | by Chris Ryan | Medium. Accessed April 24, 2022. https:// medium.com/@christelehealth/turtles-and-tortoises-enabling-mainstream-video-call-accessto-health-services-a470e8db24da. 28. Parmanto B, Lewis JAN, Graham KM, Bertolet MH. Development of the telehealth usability questionnaire (TUQ). Int J Telerehabilitation. 2016;8(1):3e10. https://doi.org/10.5195/ ijt.2016.6196. 29. Gomez RA. Reimbursing FQHCs for Telehealth Post-COVID-19 Pandemic: Medi-Cal’s OptionsdCalifornia Health Care Foundation; 2021. https://www.chcf.org/publication/ reimbursing-fqhcs-telehealth-post-covid-19-pandemic-medi-cals-options/#related-links-anddownloads. Accessed April 24, 2022. 30. Uscher-Pines L, Sousa J, Jones M, et al. Telehealth use among safety-net organizations in California during the COVID-19 pandemic. JAMA. 2021;325(11):1106. https://doi.org/ 10.1001/jama.2021.0282. 31. Digital differences | Pew Research Center. Accessed April 24, 2022. https://www. pewresearch.org/internet/2012/04/13/digital-differences/. 32. Balut MD, Wyte-Lake T, Steers WN, et al. Expansion of telemedicine during COVID-19 at a VA specialty clinic. Healthcare. 2022;10(1):100599. https://doi.org/10.1016/j.hjdsi.2021. 100599. 33. Greater Oregon Behavioral Health, Inc.dRHIhub Telehealth Toolkit. Accessed April 24, 2022. https://www.ruralhealthinfo.org/toolkits/telehealth/3/oregon-behavioral-health. 34. Consumer adoption of telemedicine in 2021 | Rock Health. Accessed April 20, 2022. https:// rockhealth.com/insights/consumer-adoption-of-telemedicine-in-2021/.

Chapter 3

Telehealth implementation in clinical practice: integration into electronic medical records and clinical workflows Nivee Amin, Krista Vadaketh, Navjot Sobti, Diala Steitieh and Tracy Paul Weill Cornell Medical College, New York, NY, United States

Introduction Telehealth utilization has become central to healthcare delivery as electronic medical records (EMR), mobile technologies, remote patient monitoring (RPM) capabilities are integrated more widely into routine clinical practice. This trend was accelerated during the 2019 novel coronavirus pandemic (COVID-19) when access to traditional medical care was limited by redirection of resources to pandemic response and to reduce transmission. With rapid adoption and acceptance of telehealth, offerings need to be integrated directly into EMRs and clinical workflows. This would include integration of technologies to deliver telehealth via telephones, video conferencing, mobile applications, electronic written communications, and may also require incorporation of RPM, clinical decision support, and other modes of patient engagement.1 Additionally, health systems may think broadly about how telehealth provides solutions for ambulatory care and inpatient care, and these applications will guide how best to integrate into the EMR and clinical workflows. As health systems or individual clinicians integrate telehealth into EMRs and clinical workflows, they will need to be mindful that advances in health delivery may further exacerbate the existing digital divide if appropriate attention is not paid toward achieving digital equity. Vulnerable populations, such as those with lower education levels, lower income levels, limited English proficiency, advanced age, and members of ethnic and racial minority groups, are at particular risk of not being equipped to participate fully in digital health Emerging Practices in Telehealth. https://doi.org/10.1016/B978-0-443-15980-0.00007-7 Copyright © 2023 Elsevier Inc. All rights reserved.

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due to many of the same barriers that lead to health disparities. Additionally, limited access to broadband internet and necessary technologies may increase disparities.2 In this chapter, we will provide guidance on essential considerations for building the foundation prior to telehealth implementation, considerations for EMR integration, and how to successfully integrate telehealth into clinical workflows. We suggest a patient-centered approach to meet patients where they are, and to engage in a continuum of care rather than episodic care. This will allow a full team of healthcare providers and clinicians to address social determinants of health, encourage shared decision making, and to promote ongoing surveillance and timely active health management (Fig. 3.1).

Pre-implementation: implementing telehealth into clinical practice Since the beginning of the COVID-19 pandemic, telehealth has been adopted widely across outpatient clinics and facilities. Given the increased demand for

FIGURE 3.1 Patient centered approach for blended virtual and in-person care. Adapted with permission from: Bhatt AB, Wasfy JH, et al. Telehealth Workbook American College of Cardiology. (https://www.acc.org/Tools-and-Practice-Support/Clinical-Toolkits/Telehealth-Workbook).

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telehealth across the United States, the healthcare industry has responded by establishing screening protocols, quality metrics for telehealth sites, malpractice coverage policies, and discrete credentialing requirements for telehealth providers. These protocols are essential for the successful implementation of telehealth into clinical practice. Before telehealth can be implemented at a given clinical practice, the site must satisfy discrete equipment requirements. Specifically, the practice must have the necessary computer software, hardware, and a reliable, secure internet connection to ensure that clinicians can deliver secure, high-quality patient care. Computers used for virtual visits, for example, should have speakers, in-built cameras, microphones, and adequate processing speeds to run the required software. Each practice should also be aware of the various federal and state-specific standards surrounding telehealth networks, connectivity, and equipment standards; this will not only help to ensure that their telehealth program is safe and effective, but also eligible for reimbursement. Site resource assessments play a fundamental role in evaluating whether a telehealth practice has met such quality metrics and is therefore equipped to provide optimal patient care. Through such site assessments, or “mock visits,” trained information technology and network staff periodically ensure that a site’s equipment and network are ready to provide efficient, safe patient care. Specific metrics that are evaluated range from the presence of a strong internet connection, adequate broadband access for the transmission of high-quality audiovisual data, and reliable data encryption to protect patient health information. Strong internet connectivity is particularly important for patients residing in areas with poor access to quality broadband internet and/or limited experience with the use of telehealth applications. Nearly one quarter of Americans do not have broadband Internet access. Those in ethnic minority groups or of lower income and education levels are less likely to have broadband Internet access in the home.3 Lack of connectivity to broadband Internet access further perpetuates the digital divide, which in turn hampers efforts to achieving true health equity. Healthcare systems, with their large economic impact in communities, must leverage their power to foster digital equity. Possible interventions include - Partnering with technology providers who have demonstrated commitment to improving broadband Internet access in traditionally digitally underserved communities.4 - Ensuring that patient portals are fully functional with the use of a smartphone, as nearly 20% of Americans most of whom have lower education and income levels solely depend on smartphones for Internet access.3 - Having patient care coordinators dedicated to signing patients up, providing some basic instruction of use, and other similar interventions.3,4 In addition to site readiness, providers must also ensure that they are aware of specific requirements surrounding telehealth practice including state medical boards, HIPAA training, and malpractice coverage. During the peak phases of the pandemic, state medical board requirements were frequently

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relaxed; however, many states now require physicians practicing telehealth to have a license in the state where the patient is located. In these scenarios, providers must adhere to the laws and regulations related to a given state’s professional licensing board. As such, providers who practice telehealth should be well-versed in the state and federal laws surrounding telehealth credentialing and reimbursement. Furthermore, physicians should also ensure that their medical malpractice insurance policy covers telehealth malpractice across whichever state(s) in which they are practicing.5 Once telehealth has been implemented at a given site, providers should comprehensively document their telehealth services. Documentation requirements for telehealth encounters are treated the same as face-to-face visits. As such, all relevant clinical details such as patient history, review of systems, medication review, and consultative care should be documented, to contextualize a provider’s medical decision-making process.6 Additionally, documentation should clearly state that the visit was conducted using a telehealth platform. Lastly, telehealth providers must comply with privacy and security rules related to the Health Insurance Portability and Accountability Act, or HIPAA. Safeguarding patient confidentiality is paramount for both the design of telehealth platforms, as well as their clinical implementation. Thus, telehealth equipment must encrypt user data.7 Despite the presence of validated data encryption software, there remains a small possibility that even encrypted data can be accessed by unauthorized/ outside parties. Smartphones and tablets pose a particular challenge as their encryption software may not be as robust as that of a computer. However, this concern should be balanced with emphasis on telemedicine accessibility for all, including those who primarily utilize their smartphones and/or tablets to access the Internet. Patients should be closely counseled regarding the limitations of HIPAA, particularly if they use their phones to obtain telehealth care, and this could be detailed in the informed consent provided to patients agreeing to participate in telemedicine.

Integration into the EMR As the medical field has rapidly shifted toward telehealth in recent years, its integration with the EMR is essential. EMRs have become the mainstay of reviewing the patient’s chart, including their medical history, medications, and prior imaging. Efficient delivery of care depends on effective integration of telehealth with the EMR. If the telehealth system is not fully integrated with the EMR, it may result in duplication of clinician effort on two disparate platforms (the EMR and the telehealth application). A seamless integration would instead improve provider efficiency by facilitating patient-clinician interactions, allowing for faster diagnoses, and reducing prescription errors. EMR integration therefore bridges the gap between patient data and telehealth and improves patient outcomes.

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The integration of telehealth into EMR is contingent on the platform used. These platforms can either be fully integrated home-grown solutions, or commercial government-certified platforms. At the onset of EMRs, the majority of hospitals and organizations developed their own platform (a “home grown” platform), though by 2007 only 20% of studies from hospitals were published using home grown EMRs.8 Determining which of these platforms to use depends on the medical system itself, where some medical systems require a custom-build solution rather than a third party. Home grown solutions are especially helpful when the needs of the medical system are very specialized, whereby an off-the-shelf product would require extensive changes to handle the everyday practice. On the other hand, if the commercial platform is too complex and large, or too expensive for your needs, then a home-grown platform would likely be a more efficient solution. The cost and tools needed to create these home-grown platforms must also be weighed, as they will require internal expertize to generate the system and update it in accordance with evolving standards.9 One of the most common ways in which telehealth has been incorporated into EMR is by integrating Zoom, a video conferencing application. Zoom has been integrated into EMR vendors such as Cerner and Epic Systems to help facilitate telehealth visits, while allowing institutions to use their home grown EMRs.10 Zoom’s integration with Cerner allows for a smooth virtual session by providers of any medical specialty, and Zoom’s integration with Epic offers similar benefits, and was first launched in 2019. Fig. 3.2 shows the typical workflow for Zoom’s integration into EMRs. The main benefit of using a system such as this is the streamlined workflow, where providers can be taken into a telehealth session directly from the patient’s visit, while simultaneously reviewing the patient’s chart. This can help improve productivity levels as you avoid having to work between two different systems. There are also patient level advantages-most patients already have the medical system’s online platform on their phones or laptops,

FIGURE 3.2 A typical example of the workflow for patients on Cerner and Epic using Zoom for telehealth.

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therefore connecting to the virtual appointment is as easy as logging into the known platform (rather than downloading a separate application). Instead of using fully integrated solutions however, medical systems can instead opt for separate telehealth platforms. Blue Jeans, Mend, Doxy Me and AMC Health are the most commonly used platforms which are HIPPA- or PHI-secure. Certain video-conferencing platforms, such as GoToMeeting and Skype, are not HIPAA- or PHI-secure. Finally, there are non-public-facing mobile communication platforms, that are not HIPAA- or PHI-secure, such as Apple FaceTime and Google Duo. The use of telehealth platforms such as Blue Jeans is accessible for patients, where they can access the visit through a link to their email, removing the need to download a separate application (which is a drawback of other independent platforms). Additionally Blue Jeans allows providers to customize the patient’s landing page, so that a medical system can still use its branding and can mirror an in-person visit. Nevertheless, independent platforms continue to have two major drawbacks: Firstly, providers must use both their EMR and the telehealth platform during the patient visit, as they are often not integrated well. Secondly, the institution must be diligent in checking HIPPA compliance and standards for the platform, as they will be responsible for the safe and private delivery of care to patients. The advantages of integrating telehealth into EMR have been widely felt, especially during the COVID-19 pandemic, which limited in-person visits at most outpatient practices. The number of outpatients were remarkably low at the start of the pandemic, however in institutions such as the Kennedy Krieger Institute that were able to quickly adapt telehealth solutions, outpatient visit volumes were back to pre-COVID-19 levels within less than 1 month.11 The pandemic has shed light on a vast number of underutilized systems, and a prominent one was telehealth. There are immense advantages in integrating telehealth and EMR. First and foremost, there is reduced clinical burden by reducing the number of steps needed for documentation and patient interaction. For instance, patients can upload their own medication list and problem history into the EMR to be quickly reviewed with their doctor, rather than reinventing the wheel. Additionally, through integrating telehealth and EMR systems one can effectively eliminate the need for duplicate data entry. For example, when a provider takes notes during a telehealth visit this information is automatically transmitted into the patient’s health record, simplifying the data entry process and reducing the chance of error when updating the EMR system. There is also streamlining of data collection that can then be used for reporting and analysis, and enhanced patient outcomes by providing pertinent patient history such as medical conditions and allergies. As a result of improved efficiency, providers can also see more patients during the day, which in turn improves the “waiting time” for sick patients. Additionally, the integration of telehealth and EMR medical systems allows synchronized patient insurance information. As insurance

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companies begin to cover telehealth services, verifying telehealth coverage can be a challenge if the patient’s insurance information is not available. Through integrating telehealth and EMR systems, however, one can quickly and accurately verify patient eligibility prior to scheduling a virtual consultation. This practice allows efficient provider reimbursement and avoids patient confusion and cost disputes. There is also a palpable improvement in the coordination of care both locally and nationally. Locally, efficiently integrated EMRs can provide the ability for members of a care team to directly communicate with each other and with the patient. In the case where a patient’s medical history is complex, they may be seeing several providers for the same complaint. Therefore, the ability for a cardiologist to see a pulmonologist’s thought process, office note, and workup, is incredibly helpful. Not only will it allow a faster more accurate diagnosis, but it also reduces duplicate testing, unnecessary treatments and therefore unnecessary expenses to the patient and the healthcare system. Moreover, primary care physicians, specialists and members of the care team can all use secure methods to communicate with each other, and if deemed necessary can also all join a multidisciplinary telehealth visit. On a national level, the integration of telehealth and EMR allows for robust health information exchange. Providers on one side of the country can rapidly share relevant patient information, diagnostic history and treatment plans. As a result, the patient’s medical care can resume uninterrupted when moving across the country, or even between institutions.

Clinical workflows: focusing on patient centered approach and best practices for telehealth visits For patients and clinicians to successfully complete a telehealth encounter, there are important considerations and best practices to be kept in mind before, during, and after the encounter. Before the visit, careful planning must be executed to ensure successful implementation. First and foremost, the right patient must be selected. As seen in the figure below, there is an appropriate workflow to work through prior to the visit (Fig. 3.3).12 The patient must be triaged to be appropriate and safe for a telehealth visit based on certain diagnostic or symptom-based keywords. If not deemed appropriate, administration should schedule the patient for an inperson visit. If deemed as appropriate, there are various previsit administrative tasks to continue in this workflow. It is crucial to ensure the patient is amenable to a telehealth visit. Social determinants of health play a fundamental role in whether patients will have necessary resources for the encounter, such as access to patient portals, working broadband internet connection, quiet space, and digital literacy to successfully participate in an encounter. These elements should be addressed by administration. If a patient does not have these necessary

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FIGURE 3.3 Workflow for telehealth visit. Certain clinical conditions have unique criteria for what is deemed safe and appropriate. Clinical judgment is suggested when developing site-specific protocols based on resources and patient safety. Adapted with permission from: Bhatt AB, Wasfy JH, et al. Telehealth Workbook American College of Cardiology. (https://www.acc.org/Tools-andPractice-Support/Clinical-Toolkits/Telehealth-Workbook).

resources, administration should help alleviate these barriers as much as able. For example, they may help to register and set up the patient in the portal, explain the telehealth visit protocol, and provide tips for a successful visit. Due to recent federal legislation, such as the Infrastructure Investment and Jobs Act and the Emergency Broadband Benefit, healthcare organizations can take an active role by partnering with community organizations located in digitally underserved areas to increase broadband Internet access among patients by obtaining government funding to expand Internet device access, increase wireless Internet access sites, and provide physical space to conduct visits in private and secure locations.13 In select cases, it would also be prudent to offer a “practice visit” to address digital literacy. The patient’s preferred language should be confirmed in order to incorporate a trained interpreter, who can easily and securely be invited into the visit via the EMR telemedicine

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platform, if needed. Accommodations should also be provided to address visual, auditory, and language needs of the patients and their respective caregivers. Once the patient is amenable and comfortable with proceeding with the visit, the patient will receive an automated email with clear instructions on how to set up the visit. The patient will also receive an e-Check-in notification to review their reason for visit, relevant medical and surgical history, and medication reconciliation. Administration should confirm any RPM devices with the patient in advance to help integrate that data into the EMR. Outside hospital records should also be obtained, such as recent electrocardiograms, lab results, remote monitoring results, and hospital records. The day prior to the visit, the patient should receive an automated email with a visit-specific link to meet with the provider, which will also serve as a reminder for the visit. Patients are asked to join the visit 15 min prior to the visit time, which serves as a time to troubleshoot if there are last-minute issues. To increase accessibility, it is important for organizations to have patient care access coordinators who are well-trained to aid in troubleshooting connection issues for patients. Patients will be asked to gather any self-monitoring data to inform decision-making during the visit. Patient-reported outcomes, such as mood, symptoms, and angina-assessment tools, will be screened for prior to the visit. When clicking on this link on the day of the visit, the patient will be placed in a virtual waiting room until the provider enters the room.6 During the visit, telehealth best practices discussed below should be utilized to achieve as much of the quality of the clinical evaluation conducted inperson as able. To begin, the patient’s symptoms should be assessed. These symptoms are the same as ones screened for during the traditional in-person visit and include surveillance of metabolic equivalents to assess functional status and screen for exertional symptoms, as well as other relevant cardiopulmonary symptoms, current diet, fluid intake, and substance use. The clinician should then review the information that was completed by the patient prior to the visit, including the patient-reported outcomes, changes to medical and surgical history, medication reconciliation, RPM data, and new outside hospital records since last visit. The objective portion of the visit is the major difference between telehealth and in-person encounters. If the patient has a blood pressure cuff and pulse oximeter at home, the clinician can ask the patient to measure those respectively. Depending on video quality, jugular venous pressure assessment may also be attempted (ACC Telehealth Workbook). Clinicians are also able to assess the patient’s breathing (e.g. nontachypneic, speaking in full sentences) and peripheral edema with adequate video quality. After the physical exam portion, the clinician has time to provide counseling to the patient, which may be more effectively provided in this environment, as the patient is more comfortable in a place such as his or her own home. This removes stressors associated with the traditional clinical environments (ACC Telehealth Workbook). Clinicians can share their screens

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to review any virtual resources to augment this counseling, including visual images of the heart for visual learners, virtual tours of pantries to assess for need for dietary modifications, etc. This is the time for shared decision making, where providers can decide on titrating goal directed medical therapy, pursuing advanced therapies, and pursuing any necessary further workup or referrals. The provider should confirm the plan with the patient and should proceed to answer any remaining questions. At this time, the provider will be able to use computerized physician order entry to order medications, labs, imaging, etc. This is more efficient than the traditional in-person visit, as there is no need to handwrite or fax prescriptions. To close the visit, it is wise to ask the patient for feedback after the visit is completed to assess for satisfaction. The clinician should proceed to finish the documentation, sign the encounter, and share the note with the patient via the EMR for open communication. After the visit, the patient should be provided with instructions, including relevant information from counseling that may have been provided, medication changes, and imaging or lab orders, which can be synthesized into a cohesive After Visit Summary and integrated into the e-Check-out process within the mobile app. The patient should also be given a precise timeframe to follow up with the provider in the future as a part of this e-Check-out process. Standardized surveys should be provided to assess quality and satisfaction with the telehealth process and to identify any potential gaps in utilization and care, especially in those with socioeconomic barriers to care.6 This constructive feedback allows for dynamic changes to be made to the workflow. Eventually, a telehealth program can measure its success by tracking its patient-reported outcomes and satisfaction, which will allow for easing of transition as telehealth matures into a standard option in the care of the cardiovascular patient.6 After the clinician has provided the patient with the appropriate information for the After Visit Summary, billing should be addressed. Depending on length of service provided by the clinician, telehealth CPT codes can be billed as 99,441 (5e10 min), 99,442 (11e20 min), and 99,443 (20e30 min) (www.telehealth.hhs.gov). This can ideally be integrated as a telehealth solution to allow for automatic connection between visit type (i.e., telehealth) and billing.14

Conclusion Teleheath is now a permanent part of healthcare delivery. While telehealth cannot substitute for the comprehensiveness of an in-person visit for certain conditions and symptoms, the ease telehealth provides to connect patients and healthcare providers in a safe, accessible virtual space solidifies its role as a necessary part of routine clinical practice. It is imperative for healthcare systems to invest in and develop a sound telehealth infrastructure by appropriately planning and creating a product that meets the needs of both the providers and the patients. Thoughtful integration of telehealth platforms into

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existing EMRs further assist clinicians in providing efficient virtual care and simplifies telehealth visit access for patients as it is through an already-known patient portal. The increased adoption of telehealth must be balanced with awareness that there is still a substantial portion of Americans who lack the digital access to fully engage in telehealth visits. Thus, healthcare systems must consider systemic approaches or collaborations with community-based or governmental organizations to improve digital access across their patient population.

References 1. AMA Digital Health ResearchdAmerican Medical Association.” American Medical Association, AMA, https://www.ama-assn.org/system/files/2020-02/ama-digital-health-study.pdf. 2. Nouri S, Khoong EC, Lyles CR, Karliner L. Addressing equity in telemedicine for chronic disease management during the covid-19 pandemic. NEJM Cata Innov Care Deli. May 4, 2020. https://doi.org/10.1056/CAT.20.0123. 3. Pew Research Center. Internet/Broadband Fact Sheet; April 7, 2021. https://www. pewresearch.org/internet/fact-sheet/internet-broadband/?menuItem¼3109350c-8dba-4b7f-ad 52-a3e976ab8c8f. 4. Clark CR, Akdas Y, Wilkins CH, et al. TechQuity is an imperative for health and technology business: let’s work together to achieve it. J Am Med Inform Assoc. 2021;28:2013e2016. https://doi.org/10.1093/jamia/ocab103. 5. Bhatt AB, Freeman AM, Mullen B. Telehealth: rapid implementation for your cardiology clinic (Updated March 24, 2020). Cardiol Magazine. March 13, 2020. 6. Bhatt AB, Wasfy JH, et al. Telehealth Workbook American College of Cardiology. https:// www.acc.org/Tools-and-Practice-Support/Clinical-Toolkits/Telehealth-Workbook. 7. Implementing telehealth in practice. ACOG committee opinion No. 798. American college of obstetrics and gynecologists. Obstet Gynecol 2020; 135: e73-e79. 8. Colicchio TK, Cimino JJ. Twilighted homegrown systems: the experience of six traditional electronic health record developers in the post-meaningful use era. Appl Clin Inform. 2020;11(2):356e365. 9. Homegrown vs. Off the Shelf: What’s Best for Your HIM System? Health IT Outcomes. August 24, 2009. 10. Phillips M. Zoom’s integration with cerner EHR and Epic EHR. EMR Finder; December 6, 2021. https://emrfinder.com/blog/zooms-integration-with-cerner-ehr-and-epic-ehr/. 11. Siwicki B. Using Zoom with Epic to Bring Telehealth to Kids during COVID-19. Healthcare IT News; July 14, 2020. 12. Workflow for Telehealth Visit. American College of Cardiology. Telehealth Workbook; 2021 (Available here). 13. Rodriguez JA, Shachar C, Bates DW. Digital inclusion as health care - supporting health care equity with digital-infrastructure initiatives. N Engl J Med. March 24, 2022;386(12): 1101e1103. 14. Billing and Coding Medicare Fee-for-Service Claims. Telehealth.hhs.gov. last updated May 17, 2022.

Chapter 4

Billing basics and fundamentals Heba Wassif1, Steven Shook2 and Stacey Singer3 1 Director, Inpatient Clinical Section Services Medical Director, Cardio-Rheumatology Cleveland Clinic’s Heart, Vascular & Thoracic Institute Assistant Professor of Medicine Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve School of Medicine Cleveland, OH, United States; 2Lead for Virtual Health, Clinical Transformation, Cleveland Clinic Staff Neurologist, Neuromuscular Center, Neurological Institute, Cleveland Clinic Clinical Assistant Professor of Neurology, CC Lerner COM of Case Western Reserve University, Cleveland, OH, United States; 3Revenue Cycle Management/Health Information Management, Cleveland Clinic, Cleveland, OH, United States

We cannot solve a problem by using the same kind of thinking we used when we created them. Albert Einstein

As new technologies and new models of care continue to emerge, providers continue to monitor the rapidly changing landscape of telemedicine coding and reimbursement. Reimbursement is the key to sustainability of any new technology. Telehealth, in its current form has been in the public domain for two decades, yet the rate of adoption had remained very low, repre senting