Patient-Centered Telehealth Best Practices: What Have We Learned?

In the year since COVID-19, wound clinicians have been utilizing telehealth services at an accelerated pace. These authors compiled a look at best practices in telehealth, offering solutions to challenges related to patients, clinicians, staff and telehealth implementation.

With the adoption of telehealth in response to the COVID-19 pandemic, virtual health care services were predicted to reach 1 billion by the end of 2020.¹ As Medicare relaxed regulations, telehealth claims increased more than 11,000% in a six-week period.² Accelerated telehealth utilization presents opportunities to generate evidence and improve services. While current literature primarily focuses on telehealth services between remote wound specialists and non-wound care clinicians, there exists a scarcity of educational resources to assist clinicians in the delivery of virtual wound care directly to patients at home.

To highlight recent lessons learned in practice, we compiled recommendations from webinars, case studies, published literature, and expert opinions and identified wound care-specific telehealth best practices. Best practices were grouped as relating to patients, clinicians and administrative staff, or implementation, and were organized under potential challenges in the delivery of telehealth services.³

In the following section, bold text represents the challenges faced in practice, with corresponding tips and best practices formatted in bulleted lists.  

Patients:

Challenge: A simple, standardized process for determining telehealth suitability is lacking.
  ●    Screen patients during in-person appointments to identify patient-level factors that may eliminate the telehealth option.⁴ Screening can be conducted via a survey embedded within patient forms, conducted by support staff, or verbally during the patient visit. Screening questions include:
    ○    Does the patient have a smartphone, computer, or tablet?⁴
    ○    Does the patient have a strong Internet connection?⁴
    ○    Does the patient have someone to assist them during the visit?⁴
    ○    Does the patient have experience using technology?^4,5
    ○    Does the patient have visual or hearing impairment?⁴
    ○    Does the patient have difficulty with manual dexterity?⁴
    ○    Does the patient display a favorable attitude toward technology and telehealth visits?^4,5
    ○    Is the patient concerned about their condition?⁴
    ○    Do you have a positive working relationship with the patient?⁴
  ●    Establish the goal of each visit and screen to identify clinical factors that may eliminate the telehealth option.⁴
    ○    Do you need to communicate bad news or test results?⁴
    ○    Do you need to obtain diagnostics (e.g., collect wound culture)?⁴
    ○    Are you or a family member worried about the patient?⁴
    ○    Does the complexity of the patient’s condition necessitate an in-person appointment?⁴
      ■    For example, while some pressure ulcers and injuries are suitable to be treated via telehealth, complex and deep wounds such as a Wagner 3 diabetic foot ulcer require in-person assessment.
    ○    Do you feel the need to “trust but verify” to ensure that the patient is telling the truth?⁴
    ○    Will a telehealth visit satisfy your documentation requirements?⁴

Challenge: Proper assessment is impeded due to patients’ inexperience with technology or an insufficient Internet connection.
  ●    Provide patients with instructional materials that outline tips for a successful visit.⁶
  ●    Demonstrate how to join a telehealth visit and rehearse steps during the in-person appointment.⁴
  ●    Encourage patients to attend telehealth visits with a technically proficient family member or aide who can assist with submitting images and focusing the camera.⁴
  ●    Contact patients prior to the visit to determine device suitability, assess Internet connection, and encourage patient portal activation.⁷
  ●    Refer to images submitted in advance of the visit when assessing wounds.⁴
  ●    Adapt documentation to acknowledge limitations.⁴
    ○    For example, if assessment of the wound is challenging due to low-quality images, use terms such as “appears to” when documenting wound characteristics, as it may be difficult to discern details with confidence (other than if the wound is of partial or full thickness).

Clinicians and Administrative Staff:

Challenge: Uncertainty exists regarding optimal scheduling protocols for telehealth visits.
  ●    Allow for a similar length as in-person appointments when scheduling telehealth visits.⁴
  ●    Communicate to ensure that the visit time accommodates both the provider and facilitating clinician’s schedule.^6,8
  ●    For home health patients, if scheduling telehealth visits at the time of the home visit, ensure reimbursement requirements for both telehealth and the home health episode of care are met.^9,10

Challenge: Roles and responsibilities of all staff members must be clearly defined in order to maintain an efficient clinical workflow.
  ●    Nurses or administrative staff should:
    ○    Prepare the encounter and add documentation templates before the telehealth visit.⁴
    ○    Complete rooming as if the patient were on site (e.g., guide the patient so that the wound is exposed).⁴
  ●    Providers should review paperwork and patient history before the telehealth visit.⁶

Challenge: The utilization of telehealth services for patients under the care of home health agencies or skilled nursing facilities requires a collaborative partnership with facilitating clinicians.
  ●    Prior to the implementation of telehealth services, develop relationships with facilitating clinicians and understand what resources are available at their organization (i.e., staff, dressings, adjunctive therapies).⁴
  ●    Before the scheduled telehealth visit:
    ○    Obtain necessary information. For example, it is helpful to ask facilitating clinicians to provide images of the wound.⁴
    ○    Communicate with facilitating clinicians to identify key topics of discussion.⁶
  ●    In home health settings, ask facilitating clinicians to:
    ○    Ensure that telehealth visits are on the patient’s schedule.⁶
    ○    Arrive early to measure the wound, upload images, and take vital signs.⁶
    ○    Enlist the help of a family member or aide in positioning the phone and working with the patient.⁶

Challenge: Clinicians must ensure that documentation for telehealth services is standardized and meets billing requirements.
  ●    Ensure that documentation meets specific payor requirements.⁴
  ●    Use documentation templates.⁴
  ●    Document as if you are being audited.⁴
  ●    Recognize that the documentation requirement for telehealth is the same as for in-person visits.¹¹
  ●    To streamline telehealth visits develop a checklist of essential, electronic medical record (EMR)-specific information for the nurse to collect.⁶ Determine a process to share this information.

Challenge: Technical limitations prevent seamless delivery of telehealth services.
  ●    Implement checklists to identify potential barriers and ensure that Internet connectivity is stable.⁴
  ●    Troubleshoot in advance by conducting pre-call tests with collaborating organizations to ensure that operating systems, browsers, and mobile devices are suitable.⁴

Challenge: Clinicians must achieve accurate wound measurement and track wound progress over time.
  ●    Ask the patient to place a ruler, a device with measurements in centimeters, or a quarter near the wound to provide dimension.⁸ Alternatively, if resources are available, an automated app to track wound assessment and measurement may be considered.⁴

Implementation:

Challenge: Telehealth services must comply with regulations and be covered by liability insurance.
  ●    Ensure that your malpractice insurance covers telehealth services, especially across state lines, and provide your carrier with an effective date.^4,11,12
  ●    Review State Practice Acts.⁴

Challenge: Keep up with reimbursement coverage policies for telehealth services
  ●    Check insurers’ coverage determinations and ensure your documentation and billing codes meet their requirements

Challenge: Organizations must identify technological needs and identify a suitable telehealth solution.
  ●    First, determine the telehealth capabilities of your electronic health record (EHR) system and decide if an external vendor is needed.¹¹
    ○    Generic EHR telehealth solutions may be sufficient for clinicians who do not need to evaluate patients with wounds.
  ●    Look for key characteristics of an optimal external telehealth software, which may include:
    ○    Secure, encrypted, and HIPAA-compliant^5,7,7,11
    ○    Easy-to-use^5,7
    ○    Interoperable⁵
    ○    Cost-efficient⁵
    ○    Accessible from desktop computers, tablets, and smartphones⁷
    ○    Patient-centered (this is essential for individualization, fostering greater autonomy in the healing process, and promoting telehealth adoption)^5,6
    ○    Compliant with the Open Notes Provision of the 21st Century Cures Act⁶
  ●    Look for key features of an optimal external telehealth software, which may include:
    ○    Ability for mobile device users to switch from the front to the rear-facing camera in order to show their wound to a remote provider during a video visit⁶
    ○    A portal that allows patients to request consultations, submit photos, access medical history, and receive educational materials⁶
    ○    Ability for patients/requesting clinicians to receive video visit links via SMS and/or email⁶
    ○    Provision of real-time instructional materials for patients (e.g., how-to video tours)⁶
    ○    Integration with clinic scheduling software⁴
    ○    Thorough documentation capabilities, such as:
      ■    Photo and wound documentation⁵
      ■    Automatic time-tracking for CPT code selection⁴
      ■    Smart/dot phrases with predefined, modifiable snippets, which allow for standardization and time saving⁷
      ■    EMR workflow integration, which enables clinicians to link patients’ photos in the hospital information system and encourages providers to utilize the technology^5,8
      ■    Patient progress management to view patient’s development over time⁵
      ■    Ability to obtain a second opinion from a colleague⁵

Challenge: In the absence of careful planning and collective decision-making, organizations may experience unanticipated challenges following implementation.
  ●    Conduct an early meeting with your team to identify:
    ○    Potential barriers⁴
    ○    Patient demographic limitations (e.g., communication barriers, access to technology)^4,8
    ○    Ways to cultivate a positive patient experience, which should be a top priority when considering telehealth implementation⁴
    ○    Nursing staff needs⁸
    ○    Coding updates in the chargemaster, needed for proper billing of telehealth services
    ○    Information technology (IT) needs (e.g., technology risk assessment, minimum requirements, etc.)
    ○    Telehealth modalities that will meet your needs.
  ●    Identify workflows tailored to the practice’s needs.¹¹
  ●    Create professional remote visit templates with smart phrases to standardize documentation for patient care and billing.⁷
  ●    Incorporate a triage pathway to determine which patients are appropriate for telehealth.¹¹

Challenge: Staff must adopt and integrate the newly introduced workflows for telehealth services.
  ●    Conduct thorough training modules with all staff:
    ○    Prior to beginning sessions, ensure that workflow integration is in place.⁴
    ○    Host multiple sessions, manually rehearse steps, and incorporate clinician feedback in the training process.⁴
 
Reference the “Telehealth in Wound Care: Best Practice and Tips for Success” infographic to view a complete visual summary of the above information.

Conclusion

As payers prepare to offer provider-to-patient telehealth services as a permanent modality, implementation of these best practices will assist in achieving optimal patient, clinician, and staff satisfaction.
 
Elaine H. Song is a plastic surgeon, and Co-Founder and CEO of WoundReference, Inc.

Catherine T. Milne is an advanced practice Wound, Ostomy Continence Nurse at Connecticut Clinical Nursing Associates, and an Advisory Editorial Board Member of WoundReference, Inc

Lauren Mitchell is a Research Intern of WoundReference, Inc.

Tiffany Hamm is an Advanced Certified Hyperbaric Registered Nurse, Certified Wound Specialist, and Co-Founder and Chief Nursing Officer of WoundReference, Inc.

Jeff Mize is a Registered Respiratory Therapist, Certified Hyperbaric Technologist, Certified Wound Care Associate, and Co-Founder and Chief Clinical Officer of WoundReference, Inc.

Kye Evans is an emergency medicine physician, Medical Director for the Lawrence Memorial Hospital Wound Healing Center, and an Advisory Editorial Board Member of WoundReference, Inc

Jayesh Shah is an internal medicine physician, President of South Texas Wound Associates and TIMEO2 Healing Concepts, LLC; Medical Director of Wound Healing Center at Northeast Baptist Hospital and Co-Medical Director of Mission Trail Baptist Wound Healing Center

Scott Robinson is an emergency medicine physician, Medical Director of Hyperbaric Medicine for the Lawrence Memorial Hospital Wound Healing Center, and an Advisory Editorial Board Member of WoundReference, Inc.

Nataliya Lebedinskaya is a wound and ostomy nurse at Kaiser Permanente, and an advisory Editorial Board Member of WoundReference, Inc.

Erin M. Tharalson is doctor of nursing practice, Wound Clinic Director for the Virginia G. Piper St. Vincent de Paul Medical Clinic, and an Advisory Editorial Board Member of WoundReference, Inc.

1.     Forrester Research. US virtual care visits to soar to more than 1 billion. Published April 10, 2020. Accessed October 18, 2020.
2.     Pifer R. Medicare members using telehealth grew 120 times in early weeks of COVID-19 as regulations eased. Healthcare Dive. Published July 27, 2020. Accessed May 28, 2020.
3.     Mitchell L, Song E, Hamm T, et al. Telehealth in Wound Care - Evidence and Best Practices. In: Milne C, Shah J, eds. WoundReference. 2021. Accessed January 11, 2021.
4.     Song E, Milne C, Hamm T. Telehealth Beyond COVID-19: Transforming Best Practice in Wound Care. Presented at the Telehealth Beyond COVID-19: Transforming Best Practice in Wound Care; June 17, 2020.
5.     Jacob C, Sanchez-Vazquez A, Ivory C. Factors impacting clinicians’ adoption of a clinical photo documentation app and its implications for clinical workflows and quality of care: qualitative case study. JMIR Mhealth Uhealth. 2020;8(9):e20203. doi:10.2196/20203
6.     Song E, Hamm T, Bowles R, Harris K. Adding telehealth to your wound care practice. Presented at the: MidAmerica Wound Healing Society Quarterly Meeting; November 19, 2020; Online and in Wichita, Kansas.
7.     Ratliff CR, Shifflett R, Howell A, Kennedy C. Telehealth for wound management during the COVID-19 pandemic: case studies. J Wound Ostomy Continence Nurs. 2020;47(5):445-449. doi:10.1097/WON.0000000000000692
8.     Engels D, Austin M, Doty S, Sanders K, McNichol L. Broadening our bandwidth: a multiple case report of expanded use of telehealth technology to perform wound consultations during the COVID-19 pandemic. J Wound Ostomy Continence Nurs. 2020;47(5):450-455. doi:10.1097/WON.0000000000000697
9.     Centers for Medicare and Medicaid Services. Federal Register : Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. April 2020.
10.     Song E. Reimbursement for Telemedicine Services in Wound Care. WoundReference. Published October 6, 2020. Accessed October 5, 2020.
11.     Shah J. Taking advantage of telemedicine for wound care during the COVID-19 pandemic. Today’s Wound Clinic. 2020; 14(6):18–19. Published June 4, 2020. Accessed December 1, 2020.
12.     Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck-the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc. March 2020. doi:10.7547/20-051