Best practices for primary care telehealth during COVID-19

Editor's note: This resource was originally published in May 2020 and no longer reflects the current status of telehealth coverage following the end of the COVID-19 public health emergency (PHE) delcaration.

The staying power of telehealth services is about to be revealed, as medical practices reopen to in-office patient visits and patients across the United States debate whether to opt for traveling to their primary care providers’ office or instead look for a virtual visit.

This transitional moment means it’s more important than ever for primary care clinics to take a closer look at how providers deliver care via telemedicine and ensure they are meeting best practices.

In a recent webinar presentation, Stephanie Gallup, senior director of implementation, Aledade, discussed the evolving landscape of telehealth and what they have seen from partnering practices nationwide.

Gallup noted that her organization “embraced telehealth with open arms” in early March, going from virtually no telehealth previously to about 85% of practices having claims data billing for telehealth in recent weeks.

Here are key takeaways on their overview of considerations in vendor selection, processes and procedures to overcome common barriers and ensure good patient experience.

Know the policy changes

Prior to the COVID-19 public health emergency (PHE), Medicare billing for telehealth services was very limited. Now, telehealth visits are paid at parity with in-person visits, and high-reimbursement transitional care management (TCM) visits are paid at parity when delivered via telehealth. “TCM visits [are] really perfect for telehealth,” Gallup noted. “The patient is newly home, they're settling in, they probably don't want to leave immediately to come in for a doctor's appointment. … They also are a huge return on investment in terms of the reimbursement for those visit types.”

Gallup cautioned that it remains important to understand state-level regulations regarding patient consent for telehealth (which must be documented in the patient’s chart within your EHR), as well as the risk coding needed for providers participating in value-based programs.

Understand personal device workflows

Commercially available audio and/or video communication technology — FaceTime, Google Hangouts, Facebook Messenger, for example — can be used to provide telehealth services to patients for the duration of the PHE. However, providers must initiate and complete the visit. “If it is an actual face-to-face physician visit, you would be doing things like the assessment, plan, documenting your visit, taking notes — all of those different visit components,” Gallup said. “That's one to one. … A lot of elements of the workflow are going to remain consistent, especially components such as documentation and assessment.”

Gallup added that providers are encouraged to notify their patients that they're using a third-party vendor to do the visit, and that all available encryption and privacy modes should be enabled. Some providers also should consider using a phone number/device that’s not their personal number/device.

In the interim, opt for vendors with low barriers to adoption

Noting that many telehealth platform/software vendors have been overwhelmed with demand and signups in recent months, Gallup noted that integrations with the practice’s EHR or patient portal are good to have in some cases, especially if patient demographics can be imported to avoid manual entry or automatic transcription of notes. However, if your EHR is “super lightweight, you may be best to use a standalone” telehealth platform, Gallup said. But most important, as Gallup noted, is how quickly providers and patients can get the platform working. The ability to allow multiple call participants in a visit is also an interesting feature to weight, especially if a patient’s family member wishes to join the call or you need an interpreter.

Additionally, Gallup cautioned to evaluate vendor contract requirements and ensure you pick a vendor that matches your needs in terms of flexibility and term. “You may or may not want to sign a yearlong or multi-year contract with a telehealth vendor,” Gallup said. “Some vendors have flexibility and will allow you to go month to month, others really lock you into a binding contract.”

Optimize your pre-visit workflow

Pre-visit workflow in telehealth “is absolutely critically important,” Gallup said. This begins with ensuring telehealth consent is done and the patient is able to gauge if his or her device is supported by the vendor’s technical specifications; additionally, the practice may want to provide some guidance to patients on being in an area with adequate WiFi or mobile coverage before a call. “You’d be really, really surprised at the number of patients that have really out-of-date iPhones or devices that were used several years ago,” Gallup said, adding that test visits with scheduling staff can help minimize the risk of technical problems when it’s time for the provider-patient visit. “Think of it as almost like a soft opening,” Gallup said.

Have backup plans

If technical issues occur, it’s important to have alternate telehealth workflow options. “Sometimes the physicians are at home, sometimes the staff are at home, sometimes the patients are at home,” Gallup noted, which present unique challenges. Gallup recommended having a centralized workstation in a private area for staff to rotate through during the stages of a virtual visit, from check-in to billing, when physicians and staff are in the office. When physicians and staff are working remotely and a third party (e.g. interpreter, family member) is needed, consider a three-way call if your platform doesn’t’ support multiple participants beyond provider and patient.

Additionally, if you experience technical issues but staff or providers can see the patient’s video, Gallup advises to take a screenshot to highlight the attempt made at video before shifting to an audio-only visit. It’s best to move on quickly from a video call with technical issues to avoid frustrating the patient, Gallup noted.

Telehealth best practices

Gallup outlined several key best practices for primary care clinics in telehealth:

• Work to prioritize patients who might be high risk if they were to be infected with COVID-19.
• If billing for TCM, time requirements in a virtual visit should be met and documented.
• Use social media channels to help patients feel more connected to their practice and about how they can receive care via telehealth. Getting patient acceptance of telehealth often “is directly proportionate to how practices are actually working with their patients” on understanding technology and telehealth, Gallup said.
• To overcome barriers with patients wary of technology, try to draw analogues to other technology they currently use, such as FaceTime or Facebook. That might include getting a patient’s family member whom they trust to help make the case.
• Stress to providers and staff that telehealth is a visit and not simply answering questions as you might do via phone or patient portal. It’s important for patients to understand that telehealth visits are not free, and that most, if not all components of the office are covered in the telehealth visit. “Just explaining the robustness of the exam that's happening is a great way to mitigate concerns that, ‘Well, you used to give me a phone call for free,’” Gallup said. “While the technology does make a difference, these visits are virtually the same. Making sure that you're applying the clinical guidelines that you would do via an office visit and applying it to this virtual world is very, very important to do.”

Technical steps for positive patient experience

A variety of technical steps also help ensure your providers and staff are achieving best practices that lead to better patient experience, Gallup said:

• Find a quiet space that ensures patient privacy, with appropriate lighting — consider blocking any light from windows and relying primarily on overhead lighting for consistency.
• Set cameras at eye level so providers and staff can maintain eye contact with a patient.
• Give your system the best opportunity to perform by closing unnecessary programs and using wired internet connections whenever possible to avoid interruptions.
• Always keep your support team’s contact information easily available when all else fails.