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Introduction   

Telehealth has become more popular and widespread across the United States. With its widespread use and popularity, more nurses and health care practitioners are required to complete courses like this Washington Telehealth Training. The earliest encounter with telehealth involved Alexander Graham Bell in 1876 when he used his telephone as a means of getting help from his assistant after he had an accident involving spilled acid on his trousers (1). The origin of telehealth officially began in 1959, with clinicians at the University of Nebraska utilizing video communication for medical purposes. These clinicians established a two-way television setup to transmit information to medical students across campus. Five years later, the setup was linked with a state hospital to perform video consultations. Telemedicine first became popular in rural areas, where populations with limited healthcare access could now reach specialists from afar. In the 1960s and 70s, the Public Health Department, NASA, the Department of Defense, and the U.S. Health and Human Services Department all invested time and money into telemedicine research.

In this Washington Telehealth Training course, the following outcomes and objectives will be reviewed:

• Discuss the background, origin, and scope of telehealth practice.
• Explain policies and regulations related to telehealth.
• Describe ways to determine if an organization is ready and prepared for telehealth and the process for the actual telehealth visit.

Telehealth Background

Definition

This Washington Telehealth Training course defines telehealth as the delivery of healthcare services using digital technology and can include services in the behavioral health field, such as substance use disorder treatment, serious mental illness treatment (SMI), and counseling. The clinic is considered the originating site (where the patient is located during the telehealth visit) and the specialist at the other location is the distant site.

In organizations that serve individuals with intellectual and developmental disabilities (IDD), telehealth is the practice of healthcare within a professionally designated scope of practice using electronic communication, information technology, or other means between a licensee in one location and a client in another location with or without an interviewing healthcare provider.

Telehealth allows patients to have better access to a variety of specialists which, in turn, increases the number of people receiving appropriate care. Overall, it can provide cost savings to the patient and increase the quality of care.

Telehealth and its Scope of Practice

The practice of nurses using telehealth is within the legal scope of practice for licensed nurses, registered nurses, licensed practical nurses, and advanced practice registered nurses (2). It can be used among these professionals as needed or when a patient is unable to make an in-person visit.

Telehealth Policy and Regulations

In-State/Out-of-State Requirements

Most providers are only allowed to see patients located in states where the provider is licensed or certified. However, many states temporarily changed this policy during COVID-19. These in-state restrictions are often due to the nature of the services a clinic provides.

Organizations can choose if they want to provide telehealth services. However, if the topic is suggested, the organization must have team members in place to discuss the options, pros, cons, and feasibility of telehealth within its practice.

Additional Credentialing and Protocols

There are no additional credentialing or privilege protocols in place for those located out-of-state as those individuals are required to seek services within their area and state. The credentialing requirements must abide by the specific guidelines set forth by each organization and these can vary from one place to another.

It is imperative that the right billing codes are used in order for the insurance company to reimburse for services rendered. Typically, there are codes known as the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS). It is important to pay attention to any changes, as these codes do change from time to time. If ever in doubt, always double-check to ensure that the codes being entered are the correct ones for proper billing and reimbursement.

Reimbursement of In-Person Visits

Telehealth visits are typically reimbursed at an equal rate to in-person visits, but the reimbursement for those with intellectual and developmental disabilities (IDD) relies mostly on Medicaid Home and Community Based Services (HCBS) waivers. The overwhelming majority of waivers permit the temporary use of telehealth services for those individuals with IDD; however, only a small percentage include the use of telehealth on a permanent basis for this population. The limitations that were noted involved those individuals that were not a part of the following services: employment, day, and prevocational services, and in-home residential supports. Controlled substances are also not allowed to be prescribed by using telehealth until an in-person visit takes place.

Ryan Haight Act of 2008

The Ryan Haight Act summarizes that no controlled substance may be delivered, distributed, or dispensed by an electronic method such as the Internet without a valid prescription and requires at least one in-person medical evaluation (3).

This Washington Telehealth Training course asks nurses to consider the following example: if a patient undergoing a telehealth visit needs to be prescribed a controlled substance, the person issuing the prescription must have a doctor-patient relationship with the patient. This may seem reasonable, but the narrow definition in the law indicates that a telehealth visit may be inadequate due to the law specifically requiring an “in-person evaluation”.

Telehealth Readiness

When an organization begins to consider whether or not telehealth service is right for them, there are four critical factors that must be considered. These four factors include 1) workflow, 2) practitioner availability and acceptance, 3) infrastructure and cost, and 4) sustainability. All of these factors must be considered when attempting to decide if telehealth services would prove beneficial to an organization. An organization must meet as a team to discuss these components in order to assure that these factors can or cannot be met successfully.

Standards of care must be implemented and followed at any given practice and specialty area. The same is true for practices utilizing telehealth. The following serve as standards of care (4):

• Training of staff – staff must be trained in the use of the technology used and must be competent.
• Evaluations and Examinations – diagnosis should be established by establishing the patient’s history, mental evaluation, physical examination, and appropriate laboratory and diagnostic testing.
• Licensee-Patient Relationship – proper identification must be made prior to any telehealth encounter. Failure to verify the patient’s identity may lead to fraudulent activity or disclosure of patient information that is confidential. The location and identity of the patient must be verified. The licensee’s name, professional credentials, and location should be provided to the patient. Appropriate follow-up care and a complete medical record must be available to the patient and other health care providers involved in the treatment plan.
• Prescribing – the concept of “Contact with Patients before Prescribing” must be practiced – other providers must be involved in ongoing care and evaluations of the patient. All federal and state laws must be followed and are expected to participate in the Controlled Substances Reporting System.
• Medical Records – complete records must be maintained and must be consistent with prevailing medical record standards. HIPAA and security related documents must be present and signed appropriately. Confidentiality must be maintained and a copy of the medical records consistent with state and federal laws must be in place.
• Disclaimers – a statement that includes any unique limitations of the electronic model being used should be present, if applicable.
• Licensure – the practice of medicine is deemed to occur in the state in which the patient is located. If the licensee intends to practice telehealth outside of their current state must first check with other state’s licensing board to ensure if this is allowed.

Protocols for the necessity of visits

Typically, most patients can receive an appointment for a telehealth visit without any difficulty as long as the following are not present: conditions causing severe pain or those requiring a detailed in-person examination, prescription and refill of controlled substances, any condition that requires in-person drug administration, highly complex medical conditions, and psychiatric emergencies.

There are certain protocols regarding the type of visit that is appropriate for telehealth and when one should be referred to an in-person visit. The following are some common types of visits that meet the standards of telehealth:

• Lab tests or x-ray results
• Recurring conditions such as migraines or urinary tract infections
• Skin conditions
• Mental health treatment, online therapy, counseling, and medication management
• Prescription management
• Urgent care issues such as colds, coughs, and stomach aches

A patient should be referred to an in-person visit when they require highly specialized care, such as cancer treatments or complex specialty care.

How to Receive a Telehealth Appointment

With most telehealth appointments, it is best and easier if the patient will download the app and initially set up an account. There is also a 1-800 number that can typically be called as well if the patient needs additional help. Each patient will need to complete a brief medical history just as one would at the doctor’s office and once submitted, the telehealth specialist will connect the patient with the right medical professional – doctor, therapist, or a specialist. The telehealth specialist will assist the patient with setting up a date/time for the appointment and the appointment can be completed by phone, video, or app.

General Overview of Telehealth Software

This Washington Telehealth Training course recommends following five things should be considered when looking to choose a platform to implement telehealth services: integration using the same interface which allows everything to be accessed; user-friendly design – all patients should feel comfortable using the platform and not frustrated; specialty care solution – look for a platform that caters to providers that provide specialty services; configuration and customization – the platform needs to be customizable to meet each patient’s unique preferences along with the preferences of the healthcare facility; data analytics – it is important to gain new insights by recoding and logging each patient interaction, which allows the organization to better manage the practice and the experiences of the patients. The collected data assists with identifying issues early and creating resolutions in a timely manner.

In general, the practice of telehealth requires a good source of internet access by all parties, supported by broadband internet connection and mobile communication. The following list includes hardware requirements:

• Desktop
• Computer
• Laptop
• Smartphone with a camera
• Tablet with a camera and microphone
• Telemedicine care

Guide on Approved Software

It is important to ensure that the software platforms used are HIPAA compliant. The list below includes vendors that represent HIPAA-compliant video communication products that are recommended by this Washington Telehealth Training course:

• Skype/Microsoft Teams
• Updox
• VSee
• Zoom for Healthcare
• me
• Google G Suite Hangouts Meet
• Cisco Webex Meetings/Webex Teams
• Amazon Chime

Obtaining Patient Consent for Telehealth

Once the patient has decided to use telehealth for an appointment, official informed consent may be required. It is important to keep in mind that specific informed consent laws vary by state, but this Washington Telehealth Training course recommends the following actions that are always a good idea to follow (5):

• Explain to the patient what they can expect from the telehealth visit and what their rights consist of.
• Check in with the patient about their responsibilities during online counseling or telehealth visits such as wearing headphones and finding a place to be alone to ensure privacy.
• Inform the patient to get anyone’s consent from the start that may be observing the patient.
• Instruct patients to complete required forms ahead of time and bring them to the telehealth visit.
• Ensure the informed consent form and any other documentation has been done during the check-in process, including verbal consent.

It is important to have your medical intake forms reviewed by the legal team. Obtaining informed consent from each patient is important to have completed before the first appointment.

Verbal consent is where a patient gives their consent to a procedure in a verbal manner and does not sign any written form. This Washington Telehealth Training course provides the following example:

My name is ________________________________ and I am verbally consenting to participate in the study. By signing above, I give permission to be a part of the study and to allow the data collected to be used for the resulting process.

IT Support Services

In order for telehealth to be productive, IT support services must be in place to ensure that all areas are fully functioning and if a problem occurs, the IT department must be available and ready to intervene 24/7/365. If a patient is experiencing problems making an appointment or with any connectivity issues, IT can be notified to assist in these areas.

Practice First

Telehealth is a relatively new technology and as it gains widespread usage it is important for each organization using telehealth to do a practice run first to ensure that all of the elements are working properly. Every platform is used differently, and it is important to understand the requirements for each one. Also, the patient may need to have an app downloaded beforehand to make the entire process smoother.

Emergency Outage Plan

Planning can go a long way to prepare for an emergency situation during a telehealth appointment. If an emergency outage situation occurs, answer the following questions with the patient before or at the beginning of their first appointment:

• What is your current location?
  • Confirm the patient’s exact location and obtain their full address.
• What is the information for your emergency contact?
  • There should always be more than one number given in case disconnection occurs.
• Do you have an alternate way of contacting the clinic if disconnection occurs?
  • If not, this needs to be made known at the beginning of the call.
• Do you have an alternate video platform to use if disconnection occurs?
  • If so, this needs to be communicated with the provider at the start of the call.

Patient Information Security/HIPAA Protocols

This Washington Telehealth Training course recommends that all telehealth services provided by insured health-care providers and health plans must comply with the established HIPAA rules according to the Health Insurance Portability and Accountability Act of 1996. The HIPAA rules are in place to ensure that both paper and digital medical histories remain private. During the actual call, the health care provider is required to call the patient from a private setting such as their office or an appointment room. The patient should also be in a private, safe location in which they can freely discuss their health.

There are four important ways to stay compliant with the telehealth HIPAA regulations, 1) check one’s remote communications, 2) double-check the tracking of data, 3) keep all vendor agreements in writing, and 4) protect any and all stored communications.

Connecting Interpreter Services to Telehealth

Many virtual meeting platforms offer an option to connect an interpreter if requested by the patient. Once conencted, a Language Line can be added to the address book that enables the interpreter to be accessed. The service assists in building trust, reducing misunderstandings, and improving the overall patient experience. The patient will be connected to experienced professionals who will securely and patiently assist those with language barriers to make important healthcare decisions. The patient can also access telehealth resources translated from English on the platform that allows the patient to view the information in their own preferred language.

Billing and Documentation Protocols

When submitting documentation for a telehealth visit, the following elements must be included: date of visit; consent for visit from the patient or patient representative (either verbal or written consent); category of office visit, real-time audio with audio/telephone or video only.

In order to ensure that medical records are accurate and supported by telehealth services, the following must be documented in the health record (6):

• Method of telehealth (video connection, phone call, etc.)
• Location of provider (name of clinic, city, home, other)
• Listing of all clinical participants, roles, and actions
• Member location (name of clinic, city, home, other)
• Time actually spent in medical discussion – start/stop times.
• Patient consent – documented confirmation or verbal consent must be documented

Telehealth Visit

Guidelines

Just as bedside manner encompasses much more superficial appearance, web-side manner transcends how an individual looks on camera, including empathy and understanding for patients regardless of physical distance. The same standards apply for in-person visits, but a patient is likely to observe and evaluate how the telehealth visit goes based on the visual manners given during the visit. The medical professional should be dressed in an appropriate and professional manner. The lighting, angle of the camera, and background are all important factors to consider when doing a telehealth visit. This Washington Telehealth Training course provides the following fundamentals for each telehealth visit:

• Ensure that all professional identification is within clear view for the patient.
• Place yourself in the center of the video frame. You are the focal point – not the background.
• Ask the patient for a contact phone number or alternative communication in case a disconnection occurs.
• If this is the first telehealth visit with the patient, consent must be obtained.
• Ensure that you are HIPAA-compliant by confirming that anyone else in the room and is approved by the patient and that the patient is comfortable performing the visit.
• Position lighting to reduce any glare or spotlights. Uniform lighting is the best and allows the patient to see your face.
• Eliminate background items which may distract the patient.
• Confirm the patient’s location to ensure you have the proper licensure.
• Ask the patient to make any rearrangements regarding furniture, lighting, or body position in order to give you a better view of the patient and a more accurate exam.

Telehealth is not for everyone or for every medical condition. It is important for an individual to discuss the risks, advantages, and disadvantages with one’s healthcare provider.

How to Start a Telehealth Visit

This Washington Telehealth Training course recommends the following four steps will help you successfully conduct a telehealth visit from start to finish:

1. Ensure the patient has the resources to schedule a telehealth appointment– patients need to be aware of how to schedule an appointment and how to contact a customer service representative if any problems arise.
2. Prepare for the telehealth visit – send the patient a reminder a day before the appointment reminding them to connect 10 minutes prior to the appointment for registration and check-in. The co-payment can also be collected at this time.
3. Conduct the telehealth visit – the provider should carefully review the patient’s chart and medical history just as they would for an in-person appointment. Additionally, any messages or information in the patient portal should be reviewed and imported beforehand. The provider should start the visit note, use the appropriate telehealth template, and begin the visit. A proper web-side manner should be implemented the entire time with intentional listening and clear communication. During the evaluation, the provider will document any complaints and symptoms reported by the patient. Note any assessments or treatment plans including the proper diagnosis codes, orders, mediations, and relevant instructions. After ending the telehealth visit, the provider should complete any documentation and sign the note.
4. Follow up and complete the telehealth coding and billing – the practice should send a follow-up text message or email the day after the appointment offering contact information for any questions or concerns with a link to a patient survey. The patient can log into the patient portal to review a summary or the visit, education resources, pay a balance, and communicate with the practice if needed.

The following can three diagnostic errors that may create issues during telehealth visits: 1) inadequate history taking due to poor or inadequate communication, 2) limited physical examinations such as the omission of auscultation and accessibility of private areas of the body, and 3 )reliance on patients and their families to accurately measure vital signs, report them, and describe physical findings.

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