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Erin Aas, MSN, ARNP, is a nurse practitioner and clinical lead for Carena Medical Providers and Carena Inc., a telemedicine solution provider. He cocreated and facilitates their virtual care training platform. He was previously a National Health Service C
To ensure providers are prepared for telemedicine practice, healthcare leaders must provide training in these areas.
In the development of any telemedicine training protocols and curriculum, it’s critical to begin with the question: Which patient is appropriate for virtual care?
In the past 10 years, the telemedicine industry has expanded rapidly to meet consumer demand for convenient healthcare. In 2016, a survey by the American Telemedicine Association found that 22% of respondents had already begun using video conferencing to speak with a healthcare provider.
This rise in utilization also reflects growing availability of virtual care options, with more health systems making telemedicine available, and more insurance plans covering virtual visits. In an effort to control rising health management costs, major employers are expected to increase their telemedicine options and coverage for employees, further expanding the demand for clinicians prepared to offer virtual care.
The need for telemedicine training
Practical training in virtual care has not been widely incorporated into medical, nursing, or continuing education curricula, which leads to confusion and uncertainty among providers. Operating in a new care medium, healthcare providers are feeling pressure to provide quality care while simultaneously considering patient expectations regarding outcomes and patient satisfaction metrics.
Last year, the AMA Immediate Past President called attention to the lack of telemedicine training, “The vast majority of medical students are not being taught how to use technologies such as telemedicine or electronic health records during medical school and residency,” he stated. “As innovation in care delivery and technology continue to transform healthcare, we must ensure that our current and future physicians have the tools and resources they need to provide the best possible care for their patients."
The AMA enacted a new policy in 2016 to encourage schools to address the gaps in training related to telemedicine.
To ensure providers are prepared for telemedicine practice, healthcare leaders must provide training in the following areas:
1. Virtual data capture
Offering virtual care is not as simple as conducting a traditional office visit over the phone or webcam. In a clinic setting, providers have specific tools at-hand to assess patients including physical exam data, point-of-care testing, or full access to existing medical records.
It may feel unfamiliar to providers to see patients without having all these data to consider in their clinical decision making. Operating in the virtual space requires different methods of gathering data and understanding how the available information should be weighted in reaching a diagnosis. Providers should feel no hesitation, and should face no penalty, for concluding that a patient should be seen in-person if adequate diagnostic data cannot be obtained virtually.
In developing a virtual care training program, it’s critical to break down the elements of an in-person visit to understand what data are available to the provider in a traditional clinic and evaluate-piece by piece-when and if that same information could reasonably be gathered in a virtual visit.
When a patient reports their medical history in the clinic, body language is an important data point for a provider to evaluate. When interacting via webcam, while some body language and non-verbal communication occurs, this may be limited by webcam resolution or lighting.
Consequently, there is more reliance on verbal communication in virtual visits, as providers and patients interact and seek to understand each other.
2. Patient safety
In utilizing new technology, the primary commitment has to be to patient safety, not treating as many patients as possible. It’s critical to review existing clinical practice guidelines as well as primary source data, and apply these to the context of telemedicine.
This helps clinicians determine which patients, symptoms, and conditions are appropriate for virtual care, and when to refer patients to be evaluated in-person. Of course, each patient is unique and has to be considered individually, but providers can never accept putting a patient at risk by assuming they have enough data to make a diagnosis if that’s not actually the case.
It is important for clinicians to understand that telemedicine is not appropriate for every patient or in all situations. Telemedicine should not be a substitute for an ongoing relationship with a primary care provider, but an extension of a care continuum.
3. Patient education
Patient education is key as well. Maybe they have never accessed virtual care before and may not understand when it is appropriate. This can lead to understandable frustration when a visit ends up with a recommendation for further in-person care or doesn’t result in a prescription that the patient had hoped for.
Providers should explain to patients that their self-reporting is the primary source of information that will be used when formulating an assessment and recommendation. The provider might illustrate this point by explaining that when the patient is in clinic and their provider uses a stethoscope to listen to their chest, this provider is collecting important data that help them make a diagnosis. In a virtual visit, though the provider can gather considerable information, he or she typically can’t use a stethoscope to listen to the patient’s heart or lungs, so the provider might not be able to safely determine the cause of the patient’s cough or other symptoms. Giving concrete examples like this helps patients understand and adjust their expectations appropriately.
Patient populations have different expectations. In telemedicine, many patients have self-diagnosed or may believe that antibiotics or a specific medication is necessary for their symptoms.
Though this is not unique to telemedicine, the convenience of a virtual visit is particularly appealing to individuals who hold such beliefs. Clinicians offering virtual care often hear, “I have this infection,” or “I need that antibiotic.” It is the provider’s job to be sure patients are receiving the safest and most appropriate treatments, which sometimes means telling them no.
Providers should be trained on strategies for these difficult conversations, on ways to explain their rationale, and how to discuss symptom management and follow-up precautions in a fashion that allows patients to feel that their concerns were heard, even if they didn’t walk away with an antibiotic prescription.
Appropriate training in telemedicine can improve provider understanding of the patients and situations that are most appropriate for virtual care, and on the nuances of this unique care modality.
Patients who have a safe and welcoming telemedicine experience are more likely to access it appropriately in the future as part of their comprehensive healthcare continuum, rather than seeing it as a replacement for in-person care.
Erin Aas, MSN, ARNP, is a nurse practitioner and clinical lead for Carena Medical Providers and Carena Inc., a telemedicine solution provider. He cocreated and facilitates their virtual care training platform. He was previously a National Health Service Corps Scholar and worked in primary care and community health.